SAMJ Vol 107, No 7 (2017) by HMPG

JULY 2017

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GUEST EDITORIAL End-of-life care and organ donation: Policy leads needed CME Wilderness medicine (part 1) IN PRACTICE Nursesâ&#x20AC;&#x2122; role in end-of-life care and organ donation CASE REPORT Blistering rash in a young male child RESEARCH Inefficient procurement undermining medicines access Interprofessional communication in organ transplantation Burden of gunshot injuries on orthopaedic resources

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JULY 2017 PRINT EDITION

GUEST EDITORIAL 3

End-of-life care and organ donation in South Africa – it’s time for national policy to lead the way J Fabian, K Crymble

EDITOR’S CHOICE CORRESPONDENCE

Standardised training is the key to accuracy in triage S R Bruijns, P Louw, A Kuiler, E Esterhuyse, Y N Magerman

Need for advocacy for maternal immunisation A Khan

HMPG CEO AND PUBLISHER Hannah Kikaya Email: hannahk@hmpg.co.za

30 days in medicine B Farham

Money isn’t everything – CMSA doctor survey shows some noteworthy results Z M van der Spuy, T Zabow, A Good Questioning male medical circumcision: Some thoughts M Smallhorne

CONTINUING MEDICAL EDUCATION

PRODUCTION MANAGER Emma Jane Couzens

GUEST EDITORIAL Wilderness medicine in southern Africa R Hofmeyr, J Matthew, R De Decker

ARTICLES Acute high-altitude illness R Hofmeyr, G Tölken, R De Decker

DTP AND DESIGN Clinton Griffin Travis Arendse CHIEF OPERATING OFFICER Diane Smith | Tel. 012 481 2069 Email: dianes@hmpg.co.za SALES MANAGER (CAPE TOWN) Azad Yusuf

Update on drowning J Matthew, C Robertson, R Hofmeyr

Wilderness cold-exposure injuries: An African perspective R Hofmeyr

IN PRACTICE 35

MEDICINE AND THE LAW The evolution of research participant protections in South Africa A Dhai

ISSUES IN MEDICINE Perceptions of nurses’ roles in end-of-life care and organ donation – imposition or obligation? K Crymble, J Fabian, H Etheredge, P Gaylard

MANAGING EDITORS Claudia Naidu Naadia van der Bergh TECHNICAL EDITORS Emma Buchanan Kirsten Morreira Paula van der Bijl

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, J M Pettifor, W Edridge, R P Abratt, D L Clarke

IZINDABA

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

CASE REPORTS First report of clinical presentation of a bite by a running spider, Philodromus sp. (Araneae: Philodromidae), with recommendations for spider bite management M Coetzee, A Dippenaar, J Frean, R H Hunt Blistering rash in a young male child C Sanders, H Potgieter

JOURNAL ADVERTISING Charles William Duke Reneé Hinze Ladine van Heerden Makhadzi Mulaudzi Charmalin Simpson Ismail Davids ONLINE SUPPORT Gertrude Fani FINANCE Tshepiso Mokoena HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Dr M J Grootboom, Mrs H Kikaya, Prof. E L Mazwai, Dr M Mbokota, Dr G Wolvaardt ISSN 0256-9574 SAMA website: www.samedical.org Journal website: www.samj.org.za

July 2017, Print edition

RESEARCH 45

Inefficient procurement processes undermine access to medicines in the Western Cape Province of South Africa B P Magadzire, K Ward, H M J Leng, D Sanders

Enough is not enough: Medical students’ knowledge of early warning signs of childhood cancer J A Geel, B T Stevenson, R B Jennings, L E Krook, S J Winnan, B T Katz, T J Fox, L Nyati

National South African HIV prevalence estimates robust despite substantial test non-participation* G Harling, S Moyo, M E McGovern, M Mabaso, G Marra, T Bärnighausen, T Rehle

Incidence of chemotherapy-induced neutropenia in HIV-infected and uninfected patients with breast cancer receiving neoadjuvant chemotherapy* S Ngidi, N Magula, B Sartorius, P Govender, T E Madiba

55 55

An increase in rates of obstetric haemorrhage in a setting of high HIV seroprevalence* E Shabalala, H M Sebitloane Mid-upper arm circumference: A surrogate for body mass index in pregnant women* A Fakier, G Petro, S Fawcus

ONLINE CONTENTS LISTED IN Index Medicus (Medline) Excerpta Medica (EMBASE) Biological Abstracts (BIOSIS) Science Citation Index (SciSearch) Directory of Open Access Journals (DOAJ) Current Contents/Clinical Medicine SAMJ SUBSCRIPTION RATES Local subscriptions ZAR1 488.00 p.a. Foreign subscriptions ZAR3 408.00 p.a. Single copies ZAR124.00 local, ZAR284.00 foreign Members of the South African Medical Association receive the SAMJ only on request, as part of their membership benefit. Subscriptions: Tel. 012 481 2071 Email: 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.

Management of failed spinal anaesthesia for caesarean section* G W Jones, R A Samuel, B M Biccard

Interprofessional communication in organ transplantation in Gauteng Province, South Africa* H R Etheredge, C Penn, J Watermeyer

An audit of traumatic brain injury (TBI) in a busy developing world trauma service exposes a significant deficit in resources available to manage severe TBI* E Jerome, G L Laing, J L Bruce, B Sartorius, P Brysiewicz, D L Clarke

The burden of gunshot injuries on orthopaedic healthcare resources in South Africa* C Martin, G Thiart, G McCollum, S Roche, S Maqungo

A finger or not? Prostate examinations by non-urologists at a South African academic institution* K Spencer

Characteristics and correlates of alcohol consumption among adult chronic care patients in North West Province, South Africa* A Bhana, S D Rathod, O Selohilwe, T Kathree, I Petersen

Please submit all letters and articles for publication online at http://www.editorialmanager.com/samj

*Abstract only, full article available online.

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Background photo: Surgically trained nurse Sebastiana Domingos, right, prepares to oversee the birth of a baby in the maternity ward of Caia District Hospital, central Mozambique | Shaun Swingler Box photos: Human kidney | Shutterstock; Rescue of a severely hypothermic mountaineer from Arangieskop, Western Cape | Rik De Decker; Linear IgA bullous dermatosis lesions | Sanders and Potgieter

July 2017, Print edition

PRINT EDITION

GUEST EDITORIAL End-of-life care and organ donation: Policy leads needed CME Wilderness medicine (part 1) IN PRACTICE Nurses’ role in end-of-life care and organ donation CASE REPORT Blistering rash in a young male child RESEARCH Inefficient procurement undermining medicines access Interprofessional communication in organ transplantation Burden of gunshot injuries on orthopaedic resources

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

GUEST EDITORIAL

End-of-life care and organ donation in South Africa – it’s time for national policy to lead the way South Africa (SA)’s healthcare system has the expertise and facilities to provide solid-organ transplantation for those with end-stage disease. In spite of this, there is a marked lack of legislation and regulatory guidelines from national to hospital level. This has resulted in a sense of uncertainty regarding the roles of healthcare professionals in the end-of-life care of terminal patients and the procurement of organs from deceased donors. Worldwide, the incidence of end-stage disease for organs such as the heart, liver and kidney continues to rise in excess of the supply of these organs. Similarly, in SA, as thousands wait on national lists, our annual numbers who receive transplants are steadily decreasing. [1] The inadequacy of our national transplant service is succinctly reflected in the SA Renal Registry data for 2014.[2] While we achieved a chronic dialysis treatment rate of 178 per million population, with most of the expansion of this service confined to the private sector, our kidney transplant rate was only 4.1 per million population. Practically speaking, this translates into many who will therefore receive prolonged interim therapy while awaiting transplant, at huge cost to the healthcare system. In the state sector, where strict rationing has resulted in limited growth, transplantation is the only mechanism (aside from death) that opens up access to the fixed number of dialysis slots. So, not only do low transplant rates compromise those who wait, they also prevent those with newly diagnosed disease from accessing care. Internationally, there has been a call for the government of each country to assume responsibility for the organ donation and transplantation needs of its society. This should be achieved by accessing its own population resources within an ethical framework that protects human rights. This is termed ‘national self-sufficiency’.[3] In SA, we have failed, and continue to fail to achieve this goal.[4] The question to ask is, why? Some may think South Africans don’t want to donate organs, or that healthcare professionals don’t support organ donation, but there is substantial evidence to the contrary. Rather, all of us would like more information that is culturally appropriate to help us make decisions.[5-9] In this issue, the article by Crymble et al.[10] explores potential reasons for low donation rates by focusing on the critical role of nurses in organ donation. This is based upon international work that has successfully addressed low organ donation rates in other countries.[11] This study confirms, yet again, that our nurses support end-of-life care and organ donation, but their knowledge base is lacking. We know this. What is new from this research, in the SA context, is how nurses are unsure of their roles in the referral process for end-of-life care and organ donation. So, despite the majority support for organ donation, far fewer nurses participate in this process because they are unclear of their scope of practice. This is particularly relevant in the relatively new field of biomedicine, in which organ donation and transplantation have challenged our definitions of fundamental concepts, such as death. What’s perhaps most encouraging is that the overwhelming majority of nurses would follow nationally endorsed clinical practice guidelines that clarified their roles. If this were to be appropriately addressed, it would hopefully result in a more active participation in the end-of-life and organ donor referral process, thereby potentially increasing deceaseddonor numbers. These findings pave the way for future research, and provide at least some potential options for consideration to address our persistently low deceased organ donor rates.

In the article by Etheredge et al.,[12] which explores communication between health professionals who are involved in transplantation, we can see the ways in which this lack of policy may manifest itself in a particularly hierarchical and stressful work environment. The article confirms the central role of nurses and transplant co-ordinators, and therefore supports the argument that clarification of roles in the process would be very helpful. As a nation, we have a collective obligation to find solutions to our ever-increasing demand for organs. Government’s commitment is critical so that we can formulate national policy for widespread public education strategies, simultaneously targeting screening and prevention programmes, while expanding organ donation and transplant services. The research presented here suggests that clinical practice guidelines should be prioritised as a matter of urgency, to clarify the roles of nurses and define their scope of practice in the end-of-life and organ-donor referral process. This could be our first step on the long road to ‘national self-sufficiency’ for South Africans with organ failure, who wait indefinitely for us to find a solution. June Fabian Wits Donald Gordon Medical Centre, Johannesburg, South Africa; and Division of Nephrology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa june.fabian@mweb.co.za

Kim Crymble Wits Donald Gordon Medical Centre, Johannesburg, South Africa 1. The Organ Donor Foundation. Transplant Statistics, 2016. https://www.odf.org.za. (accessed 14 March 2017). 2. Davids MR, Balbir Singh G, Marais N, Jacobs J. South African Renal Registry Annual Report 2014. Durban: South Africa, South African Renal Society. June 2016. 3. Delmonico FL, Domínguez-Gil B, Matesanz R, Noel L. A call for government accountability to achieve national self-sufficiency in organ donation and transplantation. The Lancet 2011;378(9800):1414-1418. http://dx.doi.org/10.1016/S0140-6736(11)61486-4 4. Moosa MR, Meyers AM, Gottlich E, Naicker S. An effective approach to chronic kidney disease in South Africa. S Afr Med J 2016;106(2):156-159. https://dx.doi.org/10.7196/SAMJ.2016.v106i2.9928 5. Gidimisana ND. Knowledge and Attitudes of Undergraduate Nurses towards Organ Donation and Transplantation in a Selected Campus of a College in the Eastern Cape. Cape Town, South Africa: University of Cape Town, 2016. 6. Etheredge HR, Turner RE, Kahn D. Attitudes to organ donation among some urban South African populations remain unchanged: A cross-sectional study (1993-2013). S Afr Med J 2014;104(2):133-137. http://dx.doi.org/10.7196%2FSAMJ.7519 7. Naude A, Nel E, Uys H. Organ donation: Attitude and knowledge of nurses in South Africa. EDTNA ERCA J 2002;28(1):44-48. 8. Sobnach S, Borkum M, Millar AJW, et al. Attitudes and beliefs of South African medical students toward organ transplantation. Clin Transpl 2012;26(2):192-198. https://doi.org/10.1111/j.1399-0012.2011.01449.x 9. Bhengu B, Uys H. Organ donation and transplantation within the Zulu culture. Curationis 2004;27(3):24-33. 10. Crymble K, Fabian J, Etheredge H, Gaylard P. Perceptions of nurses’ roles in end-of-life care and organ donation – imposition or obligation? S Afr Med J 2017;107(7):573-575. http://dx.doi.org/10.7196/ SAMJ.2017.v107i7.12487 11. Donor Identification and Referral Strategy Group, National Health Service Blood and Transplant. Timely Identification and Referral of Potential Organ Donors. A Strategy for Implementation of Best Practice. National Health Service: United Kingdom; 2012. 12. Etheredge HR, Penn C, Watermeyer J. Interprofessional communication in organ transplantation in Gauteng Province, South Africa. S Afr Med J 2017;107(7):615-620. http://dx.doi.org/10.7196/SAMJ.2017. v107i7.12355

S Afr Med J 2017;107(7):545. DOI:10.7196/SAMJ.2017.v107i7.12486

July 2017, Print edition

EDITOR’S CHOICE

CME: Wilderness medicine (part 1)

The natural beauty and wealth of wilderness environments in South Africa (SA) have kindled a nation of outdoor enthusiasts, adventurers, sportsmen and sportswomen, and a strong ethos of exploration. Today, South Africans continue to drive exploration around the globe in the name of science, the environment and other good causes. In the words of climber and writer Mark Jenkins, adventurers have ‘first-hand encounters with the world … collide with the earth … and bear witness’. The inherent risks of adventure and exploration have called for medicine to follow the path of men and women into the wilderness, providing care far from civilisation and learning from human physiology under duress. Initially the role of the enthusiastic amateur physician-adventurer, this has led to the development of the field of wilderness and expedition (or extreme) medicine. While the discipline has become well established in some parts of the world (particularly Europe and North America), Africa has traditionally been seen as the site of expeditions, rather than a role-player in the field. However, the practical experience, breadth and depth of knowledge and skill of SA medical practitioners should not be discounted. Although glamorously exotic destinations such as the Poles and Himalayas are more traditionally associated with high-profile expeditions, more aspiring summiteers die each year on 5 895 metrehigh Mount Kilimanjaro than on 8 848 metre-high Mount Everest. The diversity of African wilderness environments and outdoor lifestyle culture places our medics in an ideal position to become leaders in the field, and efforts to provide more formal training and support for wilderness medicine in SA are underway. In the spirit of growing the discipline in southern Africa, local enthusiasts and experts in the field present a series of CME articles on wilderness medicine topics, with a focus on their relevance in the region. In this issue of SAMJ, the scope stretches from ocean to mountain, discussing the risks and management of high-altitude illnesses, an update on drowning in SA, and the management of cold exposure injuries.

Perceptions of nurses’ roles in endof-life care and organ donation – imposition or obligation?

SA has a rich organ transplant history, and studies suggest that the SA public supports organ donation. In spite of this, persistently low donor numbers are a significant challenge. This may be due to a lack of contextually appropriate awareness and education, or to barriers to referring patients and families in clinical settings. It may also be due to ad hoc regulations that are not uniformly endorsed or implemented. Crymble et al.[1] present the findings of a study in Johannesburg that explored the attitudes and roles of nurses in end-of-life care and organ donation. A total of 273 nurses participated. Most were female and <50 years old. The majority expressed positive attitudes towards both end-of-life care and organ donation, but there was ambiguity as to whether referring patients and families for these services was within nursing scope of practice. The vast majority of participants noted that they would refer patients themselves if there was a mandatory, nationally endorsed referral policy. These findings have implications for clinical practice and policy, and suggest that the formulation and implementation of robust national guidelines should be a priority. Because nurses would follow such guidelines, this might lead to an increase in donor rates and circumvent some uncertainty regarding referral.

Interprofessional communication in organ transplantation in Gauteng Province, SA

Communication is essential to the transplant process, but it is challenging in SA because of the complexity of the country and the health system, the nature of transplantation as a technical procedure with inherent psychological considerations, and the large number of professionals involved. Transplant communication has not been explored in SA, and the study by Etheredge et al.,[2] which set out to explore communication in transplant settings in Gauteng Province, SA, was the first to use health communication methods to generate empirical evidence relating to it. The authors used qualitative methods to collect data across six hospitals and transplant centres in Gauteng. State and private institutions were equally represented. Health professionals and transplant co-ordinators participated. Thematic analysis of data was undertaken. Facilitators of interprofessional transplant communication included appreciation of its importance to good practice and cohesive individual transplant teams. Barriers to interprofessional communication were observed when individual teams had to come together in a multi-team, interdisciplinary environment, when interchange became aggressive, and when information was not passed on to other health professionals timeously. These barriers had implications for continuity of care and ethics, which could lead to moral distress. Transplantation in Gauteng is characterised by aspects of good teamwork, and the importance of effective communication is acknowledged. Transplantation also faces some challenges in terms of interprofessional communication. Recommendations for mitigating some of the gaps include integrating a health communication specialist into the transplant process, ‘knotworking’, the use of apology, and an advance warning text-message system for transplant professionals.

An increase in rates of obstetric haemorrhage in a setting of high HIV seroprevalence

Obstetric haemorrhage (OH) is the leading cause of maternal mortality worldwide, although, indirectly, HIV is also a leading cause of maternal mortality in some settings with a high HIV seroprevalence. Shabalala and Sebitloane[3] determined the possible association between increasing rates of OH and HIV as well as the drug treatment of HIV. The authors conducted a retrospective chart review of women with OH at King Edward VIII Hospital, Durban, SA, over a 3-year period (2009 - 2011) during which the drug regimen for the prevention of mother-to-child transmission of HIV evolved from single-dose nevirapine to antenatal zidovudine combined with intrapartum nevirapine (also referred to as dual therapy) and finally to combination or highly active antiretroviral therapy (cART or HAART). Cases of OH, including abruptio placentae, placenta praevia, unspecified antepartum haemorrhage (APH) and postpartum haemorrhage (PPH), were identified from maternity delivery records, and the relevant data were extracted. The records of 448 women diagnosed with OH were analysed. Even though the incidence of OH was low, the study found an increasing number of cases during the 3-year period. PPH – but not APH – was associated with HIV seropositivity (odds ratio 1.84, 95% confidence interval 1.14 - 2.95). cART was not associated with an increased risk of haemorrhage.

July 2017, Print edition

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EDITOR’S CHOICE

HIV was associated with a high risk of PPH, and its possible association with HIV treatment needs further research.

Inefficient procurement processes undermine access to medicines in the Western Cape Province of SA

Magadzire et al.[4] set out to identify the causes of stock-outs and to illustrate how they undermine access to medicines (ATM) in the Western Cape Province, SA. The authors conducted a qualitative study with a sample of over 70 key informants (frontline health workers, sub-structure and provincial health service managers). They employed the critical incident technique to identify significant occurrences in their context, the consequences of which impacted on access to medicines during a defined period. Stock-outs were identified as one such incident, and they explored when, where and why they occurred, in order to inform policy and practice. Medicines procurement is a centralised function in SA. Health service managers unanimously agreed that stock-outs resulted from the following inefficiencies at the central level: (i) delays in awarding of pharmaceutical tenders; (ii) absence of contracts for certain medicines appearing on provincial code lists; and (iii) suppliers’ inability to satisfy contractual agreements. The recurrence of stock-outs had implications at multiple levels: (i) health facility operations; (ii) the Chronic Dispensing Unit (CDU), which prepacks medicines for over 300 000 public sector

patients; and (iii) community-based medicines distribution systems, which deliver the CDU’s prepacked medicines to nonhealth facilities nearer to patient homes. For instance, stock-outs resulted in omission of certain medicines from CDU parcels that were delivered to health facilities. This increased workload and caused frustration for frontline health workers who were expected to dispense omitted medicines manually. According to frontline health workers, this translated into longer waiting times for patients and associated dissatisfaction. In some instances, patients were asked to return for undispensed medication at a later date, which could potentially affect adherence to treatment and therapeutic outcome. Stock-outs therefore undermined the intended benefits of ATM strategies. Addressing the procurement challenges, most notably timeous tender awards and supplier performance management, is critical for successful implementation of ATM strategies. BF 1. Crymble K, Fabian J, Etheredge H, Gaylard P. Perceptions of nurses’ roles in end-of-life care and organ donation – imposition or obligation? S Afr Med J 2017;107(7):573-575. http://dx.doi.org/10.7196/ SAMJ.2017.v107i7.12487 2. Etheredge HR, Penn C, Watermeyer J. Interprofessional communication in organ transplantation in Gauteng Province, South Africa. S Afr Med J 2017;107(7):615-620. http://dx.doi.org/10.7196/ SAMJ.2017.v107i7.12355 3. Shabalala E, Sebitloane HM. An increase in rates of obstetric haemorrhage in a setting of high HIV seroprevalence. S Afr Med J 2017;107(7):602-605. http://dx.doi.org/10.7196/SAMJ.2017.v107i7.11166 4. Magadzire BP, Leng HMJ, Sanders D. Inefficient procurement processes undermine access to medicines in the Western Cape Province of South Africa. S Afr Med J 2017;107(7):581-584. http:// dx.doi.org/10.7196/SAMJ.2017.v107i7.11356

July 2017, Print edition

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CORRESPONDENCE

Standardised training is the key to accuracy in triage

E Esterhuyse

To the Editor: We read with interest Goldstein et al.’s[1] article, ‘The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa (SA)’. It is encouraging to observe research-driven improvement in the use of the SA Triage Scale (SATS). The downstream effect of accurate triage on patient safety is known, and more effort is needed to improve the use of the SATS.[2] We are aware that training in its use tends to be haphazard (in the public and private sector), with little standardisation of what is taught in different settings by different triage trainers. The Emergency Medicine Society of South Africa provides resources for training (manuals, posters and videos), but fails to provide a structured curriculum or assessment strategy that trainers can adopt.[3] Goldstein et al.[1] mention in-service training, but unfortunately do not provide detail with regard to the training. There are several reasons why accurate triage is important. It has a direct effect on patient safety; it also improves efficiency by appropriately directing patients to receive care in order of priority.[2] In doing so, triage improves quality of care and decreases the hidden cost associated with under-, over- and no triage. Taking a step away from patient-centred motives, business-related motives, such as the use of the SATS for billing purposes, would also be affected by accuracy. It may appear to be a good idea from the outset, but as triage accuracy is likely to be either similar or (more likely) worse than that reported by Goldstein et al.,[1] this ill-conceived practice (currently used by many private emergency centres) means that an overtriaged patient is also an overcharged customer, leading to the overtriaged subsidising the undertriaged. This issue becomes murkier when one considers that the SATS purposely overtriages – a safety net, built into every major triage tool. Furthermore, the SATS triages patients to a possible admission, not a resource requirement. If a patient already pays for an admission, why must they then pay even more in the emergency centre? The key to using any instrument well, is training, practice and audit, and in the case of the SATS, it comprises continuous training and assessment. Helpful adjuncts include technology, such as the SATS application by The Open Medicine Project of South Africa.[4] However, at the core, the solution remains training. We supply a structured SATS provider curriculum (including a refresher course), with a standardised assessment, alongside instructor training, for public emergency centres in the Western Cape. We recommend the creation of a triage committee at each facility to include staff from the emergency centre and the training department. At Paarl Hospital, the Western Cape’s first facility to achieve a full cohort of SATS-trained providers using this curriculum, triage accuracy is in keeping with the national core standards set out by the Department of Health.[5] As the training programme is rolled out, more emergency centres locally are nearing this goal. An open-access SATS provider curriculum is available from our provincial website: http://www.emct.info/triage.html S R Bruijns Emergency Medicine, University of Cape Town, South Africa stevan.bruijns@uct.ac.za

P Louw Emergency Centre, Paarl Hospital, South Africa

A Kuiler Emergency Centre, Khayelitsha Hospital, South Africa

Emergency Centre, Worcester Hospital, South Africa

Y N Magerman Western Cape College of Nursing, Cape Town, South Africa 1. Goldstein LN, Morrow LM, Sallie TA, et al. The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa. S Afr Med J 2017;107(3):243-247. http://dx.doi.org/10.7196/SAMJ.2017.v107i3.11118 2. Twomey M, Wallis LA, Thompson ML, Myers JE. The South African Triage Scale (adult version) provides valid acuity ratings when used by doctors and enrolled nursing assistants. Afr J Emerg Med 2012;2(1):3-12. http://dx.doi.org/10.1016/j.afjem.2011.08.014 3. Emergency Medicine Society of South Africa. The South African Triage Scale (SATS). http://emssa.org. za/sats/ (accessed 27 March 2017). 4. The Open Medicine Project of South Africa. Mobile triage app. http://openmedicineproject.org/photogallery/mobile-triage-app/ (accessed 27 March 2017). 5. Department of Health. Core standards. A framework for the assessment of health establishments. http://www.gov.za/sites/www.gov.za/files/framework%20for%20assessment%20of%20health%20 establishments%20-%20core%20standards.pdf (accessed 27 March 2017).

S Afr Med J 2017;107(7):546. DOI:10.7196/SAMJ.2017.v107i7.12508

Need for advocacy for maternal immunisation

To the Editor: Even in the current era, many vaccine-preventable diseases, such as measles, polio and hepatitis B, still constitute a significant public health burden despite effective vaccines being available. Various factors contribute to reduced vaccine coverage, such as war-ravaged countries, rural areas with lack of access to healthcare, and the anti-vaxxers, who refuse vaccination, stemming from the disproved measles, mumps, rubella vaccine claims. This leads to disease outbreaks with considerable morbidity and mortality, e.g. measles outbreaks in developing and developed countries. Besides the advocacy needed for childhood immunisation of vaccine-preventable diseases worldwide, there also exists a need for advocacy with regard to maternal immunisation that healthcare professionals and the public are not well aware of. Maternal immunisation – vaccination of pregnant women – has been shown in trials to protect both the mother and her infant from many vaccine-preventable diseases.[1,2] Transplacental transfer of maternal IgG antibodies provides passive immunity to the infant in the first 6 months of life.[3] As a pregnant healthcare professional seeking vaccination, I was surprised to discover that many obstetricians are unaware of the benefits of maternal immunisation and do not make any recommendations to their pregnant patients. The South African (SA) National Institute for Communicable Diseases recommends inactivated influenza vaccine for all pregnant women at any stage of pregnancy during the influenza season.[4] Pregnant women are at increased risk of severe or complicated influenza and adverse birth outcomes.[4] A randomised placebo-controlled trial in SA found the influenza vaccine to be safe and effective in both HIV-infected and HIV-uninfected women and their infants.[5] The influenza vaccine is not licensed for infants <6 months of age who are vulnerable to severe or complicated influenza.[4] Maternal influenza immunisation has been shown to protect infants for the first 6 months of life.[5] Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination of pregnant women has been implemented in the UK and the USA since 2012.[3] Pertussis outbreaks in the USA resulted from the lower duration of protection from the acellular v. the previous whole-cell pertussis vaccines.[6] Locally, in KwaZulu-Natal, there were diphtheria outbreaks, and pertussis cases occur nationally.[7,8] The need therefore exists in our setting to protect infants before they develop immunity from the infant vaccine series.

July 2017, Print edition

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CORRESPONDENCE

Vaccines in development for maternal immunisation are for the respiratory syncytial virus, which causes bronchiolitis and pneumonia and is a major cause of morbidity and mortality in children, especially infants, and for group B streptococcus, which is a leading cause of invasive infection within the first 3 months of life.[9,10] There is a misconception among the general public that all vaccines are unsafe during pregnancy; education by healthcare professionals and media communications to dispel false beliefs are required. With the influenza season on the horizon, I urge healthcare professionals to recommend maternal influenza vaccination. Maternal immunisation has the potential to improve maternal and infant health outcomes. Aabida Khan Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, and National Health Laboratory Service,

1. Swamy GK, Beigi RH. Maternal benefits of immunization during pregnancy. Vaccine 2015;33(47):64366440. https://doi.org/10.1016/j.vaccine.2015.08.035 2. Omer SB. Maternal immunization. N Engl J Med 2017;376(13):1256-1267. https://doi.org/10.1056/ NEJMra1509044 3. Chu HY, Englund JA. Maternal immunization. Clin Infect Dis 2014;59(4):560-568. https://doi. org/10.1093/cid/ciu327 4. National Institute for Communicable Diseases. Healthcare Workers Handbook on Influenza. http:// www.nicd.ac.za (accessed 10 May 2017). 5. Madhi SA, Cutland CL, Kuwanda L, et al. Influenza vaccination of pregnant women and protection of their infants. N Engl J Med 2014;371(10):918-931. https:/doi.org/10.1056/NEJMoa1401480 6. Gambhir M, Clark TA, Cauchemez S, Tartof SY, Swerdlow DL, Ferguson NM. A change in vaccine efficacy and duration of protection explains recent rises in pertussis incidence in the United States. PLoS Comput Biol 2015;11(4):e1004138. https://doi.org/10.1371/journal.pcbi.1004138 7. Annamalai M. Diphtheria and the respiratory system: Lessons from 2015 outbreak. S Afr Respir J 2016;22(2):38. https://doi.org/10.7196/SARJ.2016.v22i2.75 8. Muloiwa R, Dube FS, Nicol MP, Zar HJ, Hussey GD. Incidence and diagnosis of pertussis in South African children hospitalized with lower respiratory tract infection. Pediatr Infect Dis J 2016;35(6):611616. https://doi.org/10.1097/INF.0000000000001132 9. Mazur NI, Martinรณn-Torres F, Baraldi E, et al. Lower respiratory tract infection caused by respiratory syncytial virus: Current management and new therapeutics. Lancet Respir Med 2015;3(11):888-900. https://doi.org/10.1016/S2213-2600(15)00255-6 10. Chen VL, Avci FY, Kasper DL. A maternal vaccine against group B streptococcus: Past, present, and future. Vaccine 2013;31:D13-D9. https://doi.org/10.1016/j.vaccine.2012.12.080

Inkosi Albert Luthuli Central Hospital, Durban, South Africa S Afr Med J 2017;107(7):547. DOI:10.7196/SAMJ.2017.v107i7.12551

aabida.khan1@gmail.com

July 2017, Print edition

ADVERTORIAL

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and each child develops at a different pace. It could also stem from being in a very deep sleep or a bowel issue like constipation. Bedwetting could also be caused by psychological problems that has resulted from issues at school or a change in family dynamics. As a healthcare professional, providing parents with guidance and support on how to manage this very sensitive subject is key. It is important to assist parents in realising that bedwetting is nobody’s fault; it is not linked to the way in which parents have raised their child and more importantly, it is also not the child’s fault. The best thing a parent can do for a child that experiences bedwetting, is to not make this too big of a deal when it happens & reassure the child that it was just an accident. This will help to maintain their confidence and self-esteem. DryNites® Pyjama Pants can also be recommended to parents, as they have been designed to assist parents and children to confidently manage bedwetting.

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ADVERTORIAL by Dr Lance Coetzee

Robotic surgery in Africa: a quantum leap in the management of diseases such as prostate cancer, kidney cancer and bladder cancer Dr. Lance J.E. Coetzee, The Urology Hospital, Pretoria MBChB, Mmed (Urol.), FCS (SA) (Urol.), Fellow in Uro-Oncology, Duke University, USA

Robotic surgery was introduced to South Africa in October 2013 and has since been gaining traction and popularity in the management of prostate and kidney cancer, as has been the trend in most developed countries. Today, over 1 800 robotic radical prostatectomies have been performed in South Africa, over half of these at The Urology Hospital, Pretoria -- the first institution to introduce robotic surgery into South Africa. The challenge has always been that, because the technology is slightly more expensive than traditional open surgery, the justification for its use had to lie in improved outcomes and/or costs that were at least comparable with open surgery and/or radiation therapy (brachytherapy or so-called triple therapy with brachytherapy/external beam radiation/hormone suppressive therapy with or without a prior transurethral resection of the prostate prior to treatment). Additionally, the long-term outcomes would have to balance this and exceed the outcomes from previous treatment modalities. This has been shown in a number of studies in both Europe and the United States (US) and is the reason why this technology has gained traction in the US where today, if you are diagnosed with prostate cancer, over 80% of patients are managed with robotic surgery. At The Urology Hospital, Pretoria, 10 urologists have now been certified to perform robotic radical prostatectomies. Of these, two have been certified by Intuitive Surgical to act as local proctors, authorised to train surgeons in roboticassisted prostatectomies. Nationally, five surgeons have been certified to perform robotic partial nephrectomies (removal of malignant tumours from the kidneys while preserving the majority of the kidney and its functions in the process). Although this is an exciting application of robotic surgery, the volumes of patients with malignant kidney tumours are far less than with prostate cancer and I will therefore focus on the outcomes of robotic radical prostatectomies performed for patients with prostate cancer. The summarised data presented is data of Dr Lance Coetzee who has performed just under 500 robotic assisted prostatectomies and focusses mainly on aspects such as urinary continence, preservation of potency (erectile function) at six months and more importantly, on cancer control and positive surgical margin rates compared to older techniques which equate to local cancer control. The majority of patients operated on are between the ages of 50 and 70 with about 20% of patients outside this range in their 40s or between 70 and 75. Hospital stay was 2.2 days. Only one patient needed a blood transfusion and catheters were removed at an average of six days. As has been found in other series, the results in terms of urinary continence, preservation of sexual function and obtaining negative surgical margins was very much related to the volume of surgery performed by the individual surgeon. It has been documented that high volume surgeons (as was the case with open surgery) have better results and for this reason this technology should be placed in centres of excellence where high volumes of prostate cancer surgery is done (Thompson JE et al,Europ. Urol. , 2014). This has also been the experience in the United Kingdom and the US where outcomes have been excellent in high volume centres and complication rates have been low.

Urinary continence rates:

Urinary incontinence is obviously one of the big fears men have of prostate cancer surgery. The ﬁgures are often wrongly quoted for some reason to try discourage men from undergoing surgery for prostate cancer. The ﬁgures in the

ADVERTORIAL by Dr Lance Coetzee current series were as follows: 88% complete continence within 6 months, 96% at 9 months and 99% at 12 months. Patients therefore very quickly progressed to a point where they might have a few drops of urine leaking if they cough or sneeze, but on the whole, had very good control early on after surgery. Ficarra V et al., (2010, level 2b evidence) presented the combined meta-analysis of robot assisted radical prostatectomy versus open surgery in a number of large series in Europe and the US and in most of the large series the outcomes indicated signiﬁcant beneﬁt in the outcomes of robotic radical prostatectomy over open traditional retropubic radical prostatectomy (odds ratio 2,42).

Potency:

This was evaluated in patients who had good potency function prior to the surgery and in whom the tumour was picked up at a stage whereby doing a bilateral nerve sparing procedure, the cancer control was not compromised. In these patients, potency preservation at 9 months was 78% and this was maintained through 12 months. This was in keeping with the ﬁndings of the University College Hospital in London by Prof. John Kelly et al. who had a 75% potency preservation where bilateral nerve sparing was done at 9 months.

Cancer control:

The overall positive surgical margin rate in a number of large series around the world including Prof Vip Patel in Florida US, was 12%. In the series of Dr Lance Coetzee, the positive margin rate was 11.75% which is exactly in keeping with some of the large series in both the US (Patel et al.) and in Europe. The open retropubic radical prostatecomies’ positive surgical margin rate in a number of large series was 24% (J Endo Urology, vol 24, 2010). The implication of this is that with better vision aﬀorded by robotic surgery in a high volume centre, there was a signiﬁcant decrease in the positive margin rate implicating a more complete removal of the cancer which should translate into better curative outcomes.

Complication rates:

The traditional Clavian-Dindo classification was used and in terms of grade 3 and 4 complications, the robotic surgery series had a 2.2% complication rate versus 5.6% for open retropubic radical prostatectomy. On top of this, important to most men who are still engaged in active working lives, the return to work was significantly reduced within the robotic surgery group with a large number of patients returning to work within 10 to 14 days versus 6 weeks after the open retropubic or perineal radical prostatectomy. In summary, this technology has significantly improved outcomes of surgical control in prostate cancer. This has not been as clear in either low volume centres or where relatively inexperienced robotic surgeons have had their results compared with those of very experienced open surgeons. As surgeons have become more competent and more comfortable with the technology and as surgical times have reduced, the costs involved have balanced well with traditional open surgery due to reduced hospital stay, reduced blood loss and reduced need for high and intensive care in post-operative management. All the above reasons have resulted in this technology becoming increasingly more popular in most developed countries, including the US, Europe and Far East countries such as Japan, Australia, and others. Having said that, it will continue to be well managed with intensive training programmes and stringent criteria required for all surgeons involved in this form of treatment before being signed off to perform this surgery. We trust that as funders become more comfortable with this technology and see the improved results and benefits to their members, there will be increased support leading to an increased number of patients having access to this exciting technology with improved outcomes and comparable costs to the funders.

For more info on robotic surgery, contact Dean Fossett on 061 031 0618 or visit www.pinnaclesurgical.co.za.

These open-access articles are distributed under Creative Commons licence CC-BY-NC 4.0.

IZINDABA

30 days in medicine Don’t avoid all nuts – advice for patients with nut allergies

Thrombocytosis points to cancer

Patients with a peanut or tree nut allergy should not be advised to avoid all nuts – so says the first single guidance on managing and preventing nut allergy. The guideline was drawn up by the British Society for Allergy and Clinical Immunology (BSACI) and states that although complete nut avoidance is the safest approach, this is difficult in the real world and can lead to a severely restricted diet. The advice is that patients can carry on eating nuts that they know are safe at home, but should avoid nuts when out because of the risk of cross-contamination. Nut allergy is common, affecting at least one in 50 children and one in 200 adults. Most patients do not outgrow the allergy. Because most patients are looked after by health professionals with no formal training in allergy, they receive inconsistent care and advice. The BSACI guidelines were developed over the past 5 years and state that all patients should have a comprehensive management plan, including advice on avoiding nuts, recognising individual nuts, treating allergic reactions and training in using adrenaline selfinjectors. Introducing peanuts early in the weaning diets of infants at high risk of peanut allergy can prevent the allergy from developing, and there is no evidence to support the delayed introduction of peanuts into an infant’s diet. Stiefel G, Anagnostou K, Boyle RJ, et al. BSACI guideline for the diagnosis and management of peanut and tree nut allergy. Clin Exp Allergy 2017;357:719-739. https://doi.org/10.1111/cea.12957

Smaller doses, in combinations of medicine, may be effective in treating hypertension

Quarter-dose combinations of antihypertensives appear effective in treating hypertension and have fewer side-effects than a single dose of one drug, according to research published in the journal Hypertension. Researchers analysed and compared results from 42 trials, including 20 284 people with hypertension who were treated with various medications in varying doses, or taking no medication. The review included medications from the five main classes of antihypertensives, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers and thiazides. They found that two medications in combination, each at a quarter dose, were as effective as one medication at standard dose. Four medications in combination, each at a quarter dose, were nearly twice as effective as taking one medication at standard dose. The side-effects from single and dual quarter-dose therapies were about the same as those of placebo and far less than those from a standard dose of a single antihypertensive. Bennet A, Chow CK, Chou M, et al. Efficacy and safety of quarter-dose blood pressure-lowering agents: A systematic review and meta-analysis of randomized controlled trials. Hypertension 2017;70:85-93. https:// doi.org/10.1161/HYPERTENSIONAHA.117.09202

Patients with a blood test showing thrombocytosis should be screened for occult cancer. This is the finding of research from Exeter, UK. Researchers used the UK Clinical Practice Research Datalink and the English Cancer Registry to look for a link between the results of full blood counts taken in primary care and a diagnosis of cancer during the following year. They compared 40 000 patients aged >40 years who had a first thrombocytosis event – a platelet count of more than 400 × 109/L – recorded from 2000 to 2013 with 10 000 matched controls with a normal platelet count. They found that 1 098 of 9 435 men with thrombocytosis had cancer diagnosed during the following year, compared with 106 of 2 599 men without thrombocytosis. Results were similar in women. A second raised platelet count within 6 months raised the risk of cancer further, to 18.1% in men and 10.1% in women. The cancers commonly diagnosed in patients with thrombocytosis were lung and colorectal, and a third of these patients had no other symptoms indicating malignancy. Thrombocyctosis has previously been recognised as associated with lung, colorectal and urogenital cancers, and this is the first study to estimate the overall risk of cancer in patients with thrombocytosis. Bailey SER, Ukoumunne OC, Shephard EA, Hamilton W. Clinical relevance of thrombocytosis in primary care: A prospective cohort study of cancer incidence using English electronic medical records and cancer registry data. Br J Gen Pract 2017;67(659):e405-e413. https://doi.org/10.3399/bjgp17X691109

Chronic pain may contribute to dementia

A study published in JAMA Internal Medicine suggests that older people with persistent pain show faster declines in memory as they age and are more likely to have dementia later than those without pain, suggesting that chronic pain may be related to the changes in the brain that contribute to dementia. The researchers analysed data from 10 000 participants aged ≥60 for 12 years. Those who said they were persistently troubled by moderate to severe pain in both 1998 and 2000 had a 9.2% faster decline in memory over the next 10 years than those who did not have pain. The patients who complained about persistent pain also had a small but significantly increased likelihood of developing dementia. The additional amount of memory decline in those who reported persistent pain suggested that these patients would be likely to have a harder time with tasks of daily living, such as independently managing their medications and finances. Whitelock EL, Diaz-Ramirez LG, Glymour MM, et al. Association between persistent pain and memory decline and dementia in a longitudinal cohort of elders. JAMA Int Med 2017;(epub 5 June 2017). https:// doi.org/10.1001/jamainternmed.2017.1622

B Farham Editor ugqirha@iafrica.com

July 2017, Print edition

IZINDABA

The most significant reason doctors gave for leaving the public sector was dissatisfaction with working conditions. Workplace security was also tabled as a more important factor than financial remuneration. The z-score of the hypothesis test of the proportion of doctors who rated ‘Better working environment’ as 10 compared with the proportion who rated ‘Better workplace security’ as 10 was 9.7838. The difference between these two proportions is significant at a 0.05 significance level. Not only were these cited as the main reason for leaving public service by doctors who had done so, but they were the main reasons given by doctors who worked in the public sector for why colleagues had left. From a policy perspective, this sends a clear message. Workplace conditions must be considered as an integral part of any initiative to retain doctors in the public sector. Fig. 1 reflects the responses given for each reason for leaving or considering leaving the public sector. Respondents were asked to score the importance of reasons for leaving the public sector, scored from 1 (less important) to 10 (very important). From Fig. 1 it is very clear that the need for a better working environment is the main

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The most significant reason given by doctors for to why they would choose to emigrate was personal and family safety and security. The second most important consideration was the attraction of a better working environment. The z-score of the hypothesis test of the proportion rated working environment’ 1 2 of3 doctors 4 5 who 6 7 8 ‘Better 9 10 as 10 compared with the proportion who rated ‘Better personal and family security’ as 10 was 5.018. The difference between these two proportions is significant at a 0.05 significance level. Once again, doctors who had not emigrated cited these reasons as the main reason why they believed colleagues had chosen to leave SA. Interestingly, better financial remuneration was considered a less important reason why doctors thought colleagues had chosen to work outside SA. While there is little that healthcare policy makers and stakeholders can do to address personal safety and security, as this is a national issue, all parties need to be aware that this has widespread ramifications. Fig. 2 reflects the responses given for each reason for leaving or considering leaving SA. Respondents were asked to score the importance of reasons for leaving SA, scored from 1 (less important) to 10 (very important). From Fig. 2 it is very clear that better personal and family security was the main consideration for over 60% of the respondents (across both the public and the private sector). The view that personal and family security, a better working environment and personal and domestic factors were more important was also supported by the views cited as to why colleagues chose to work outside SA. Be

A total of 2 229 doctors completed the CMSA survey, revealing some interesting results.

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There are many theories as to why medical doctors choose to leave public service and emigrate. Remuneration is most often postulated as the main driver, with stakeholders resigning themselves to the fact that this is the lot of a developing country and there is little that can be done to reverse this trend. But is the lure of the dollar and the pound the main driver of emigration? Is money the main reason why doctors leave public service? To help stakeholders gain a better understanding of these matters, the Colleges of Medicine of South Africa (CMSA) conducted a survey to test doctors’ attitudes on key matters. This survey was initially distributed to the CMSA membership and later by the South African Medical Association (SAMA) to its members. The main objectives of the survey were to better understand: • Why doctors move from the state sector to private practice • Why doctors choose to emigrate • Doctors’ views on whether their working environment is conducive to delivering quality care.

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South Africa (SA) can ill afford to lose medical doctors to emigration. Retention of skills is critical for the functioning of the public sector that needs to deliver on the healthcare needs of over 80% of South Africans. Unfortunately, we continue to see two trends in our healthcare industry, these being: • Medical doctors leaving SA • Shortages of medical doctors wishing to fill key posts in the public sector, due to the migration of doctors into the private sector or abroad, or posts being frozen or becoming unfunded.

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Money isn’t everything – CMSA doctor survey shows some noteworthy results

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The working environment

The good news that came out of the survey was that SA doctors find their work satisfying and rewarding, with only a slight difference in private sector doctors being more positive in this regard. Doctors also reported having good working relationships with their colleagues and reasonable senior support. There were, however, noteworthy views regarding the workplace environment, many of which showed statistically significant differences between doctors in private practice and those in the public sector. Doctors’ views on the availability of medicine and supplies being adequate differed significantly between public sector and private sector participants, with 60.73% of public sector doctors dissatisfied with the adequacy of supplies v. 10.15% of private sector doctors (p=0.0000). A similar view was demonstrated with regard to lack of appropriate equipment/infrastructure, with 66.37% of public sector doctors indicating concern over lack of equipment and infrastructure v. only 20.41% of private sector doctors having this view (p=0.000). A similar response held true for views on facilities being of a good general standard, e.g. hygiene and management of services. In the public sector, 38.78% of employees were dissatisfied with the general facility standard v. only 5.37% of private sector doctors (p=0.000). A major concern reflected by the survey was adequacy of nursing care. Both public and private sector participants reported that nursing and other support staff were inadequate. In the private sector, 21.5% of doctors were dissatisfied with support staff v. 47.55% of public sector doctors. This finding was significant (p=0.0000). Given this input, it is not surprising that the main reason given for leaving the public sector was to ensure a better working environment.

Both private sector and public sector doctors were unconvinced that the implementation of National Health Insurance and the introduction of the Certificate of Need would improve the delivery of healthcare in SA. Most participants agreed that financial remuneration is important. Promotional opportunities were considered more important by public sector doctors. Opportunities for spouse and family were also considered key in determining where doctors work. Survey participants agreed that equal opportunities for both genders and all races are important. Opportunities for further study and research were also viewed as important, especially by public sector doctors. Also of particular interest is that 593 participants, who were working in SA (and had qualified in SA), reported having worked internationally at some stage. The main reasons given by this group for working outside SA were travel (international experience) and financial (income generation). This suggests that many SA doctors work internationally for a period and then return to contribute to our healthcare provision. From a policy perspective, we need to guard against the view that doctors who work overseas are permanently lost to SA health. Participation in the survey was fairly spread between doctors working in the public (n=1 108) and private (n=959) sectors. Most participants were working in SA (n=1 840), the majority in Gauteng (n=500), Western Cape (n=407) and KwaZulu-Natal (n=271) provinces. The main current clinical roles of participants were specialists in private healthcare (n=675) and specialists in public service (n=627). This was expected given the nature of CMSA membership, although we had hoped that the SAMA distribution would result in more responses from recently qualified colleagues. Acknowledgements. The CMSA appreciates the co-operation and support from SAMA and its willingness to assist with the survey, which was part of the project ‘Strengthening Academic Medicine and Specialist Training’. The full survey write-up is available from the CMSA on request. Author contributions. The authors contributed equally to the writing of this article. Funding. Funding for this project was provided by Life Healthcare. Conflicts of interest. None.

Zephne M van der Spuy, Tuviah Zabow University of Cape Town, South Africa, and Colleges of Medicine of South Africa Andrew Good LifeChoice, South Africa S Afr Med J 2017;107(7):550-551. DOI:10.7196/SAMJ.2017.v107i7.12643

July 2017, Print edition

IZINDABA

Questioning male medical circumcision: Some thoughts It sounds like a fantastic deal: circumcise 80% of HIV-negative, sexually active South African (SA) men (aged 15 - 49), and we will all benefit from the consequent risk reduction of 60%. Such a great deal that the US President’s Emergency Plan for AIDS Relief (PEPFAR) intends to provide USD24 million over the 5 years from end 2017 to ramp up the effort, a nice addition to extensive funding already invested in voluntary male medical circumcision (VMMC). The scientific case has been made, says Dr Themba Moeti, chief executive officer of the Health Systems Trust; after all, three randomised control trials in Kenya, SA (Orange Farm) and Uganda demonstrated the achievement of 60% reduced risk for heterosexual men through vaginal intercourse.[1-3] ‘In high-prevalence epidemics like ours where heterosexual transmission is the main mode of transmission driving the epidemic, MMC [male medical circumcision], if scaled up adequately, can make an important contribution to reducing HIV transmission and incidence.’ MMC is, as Morris et al.[4] write, ‘… a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction’. A snip that can be done at relatively low cost at community clinics – one such clinic, Asiphile, outside eThekwini in KwaZulu-Natal, Durban, having gone ‘from zero circumcisions in 2010 to approximately 10,000 clients circumcised by 2012. The follow-up rates were 87% returning for first visit and 50% to the second; 1.8% minimal adverse events; and 88% staff retention rate – making it among the most successful VMMC services in Africa.’[5] What’s not to like about that? Well, this is, after all, an epidemiological effort; if the targeted levels are not reached, it will not create the desired downward swing on the infection graph. And while uptake was initially good in African countries, where it was hoped that 20 million circumcisions could be achieved by 2016, as at October 2016, the numbers had reached only 56% of that.[6] SA’s goal for the national MMC programme rolled out from 2010 was 4.3 million by 2015. But as at the end of 2016, only just over 2.3 million SA men had been circumcised.[7] Just over half the target figure has been achieved, and we’re a year over the original deadline. When can we reasonably expect to hit the target – and how much more funding will we need to do so?

Tracking effectiveness

In the HIV and TB Investment Case[8] (which looked at all possible HIV and TB interventions), says Moeti, MMC was assessed as good value. ‘In the period 2011 - 2013, spending on MMC represented approximately 2% of the spending across the SA investment case categories,’ he says – not a huge amount. But if the intervention is stalling, should we not be asking questions about how effective the programme is overall, and whether we can rejig it in some ways to make it, firstly, more appealing (to achieve better coverage) and secondly, to give us a better bang for our bucks by achieving multiple aims? Who is keeping track of the impact of the MMC campaign – not just on the new infection rate, but also on such intertwined and sensitive issues as changes (or not) in sexual behaviour, power dynamics and understandings of masculinity in a range of societal contexts, and long-term wellbeing for circumcised men and their partners?

Questions like these have been raised by academics and scientists working in other disciplines – ethnography, anthropology and psychology, for example – but focus on the push simply to perform more and more of these medical procedures has been so intense that an adversarial atmosphere has arisen – question MMC, says one academic, and you could be accused of nasty things such as being an AIDS denialist. But people from these non-medical disciplines have some crucial insights to offer. In her unpublished article ‘A living laboratory? Male medical circumcision in Swaziland’, for example, Dr Nolwazi Mkhwanazi, senior lecturer (with a PhD in social anthropology) at the University of the Witwatersrand, identifies some instructive factors that turned a well-funded, concerted year-long drive to circumcise 80% or 152 000 of the Swazi kingdom’s HIV-negative males aged 15 - 49 into a damp squib. The campaign was called Soka Uncobe, but it did not ‘circumcise and conquer’, as the siSwati words promised. Ultimately, the campaign fizzled out with a little over 20% of its target achieved – around 32 000[9] – a result which has probably had almost no impact on the rate of infection in a country with the highest incidence level in the world. Why did it fail?

Fears and misperceptions

‘A lot of the men were afraid of becoming a statistic,’ Mkhwanazi said in an interview. She writes: ‘… many Swazi men voiced the concern that while they were aware that there was a small risk of the procedure going wrong, they feared that they would be the unlucky statistic. Some men pointed out that they simply did not want to put themselves at a risk of having a botched circumcision.’ These fears are echoed in an SA 2012 master’s dissertation on perceptions around MMC back in this country:[10] ‘… fear of pain and medical complications were the most frequently identified barrier to MMC. Thirty percent of the sample declared that overcoming the fear of physical harm and pain was a significant challenge in their decision.’ Some Swazi men did not see the value of a procedure that only offered 60% protection, writes Mkhwanazi. ‘Others said that they did not see the need for men to be circumcised if after the procedure men still had to wear condoms during sexual intercourse.’ Without careful counselling to explain what is meant by a 60% reduction in risk, there may be misconceptions that lead to problems for partners. In an interview, Marion Stevens (chair: Sexual and Reproductive Justice Coalition, and research associate: African Gender Institute, University of Cape Town) offered some anecdotal evidence that at least some women whose partners have had MMC feel less safe than they did before – a misperception of the extent of the man’s protection following the procedure, a feeling that ‘I’m totally safe now’, sometimes leading to risky behaviour that worries the woman. Long-term, habitual shifts in sexual behaviour are key to reining in the disease: if men don’t understand that they must still protect themselves and their partners after the procedure, what does this say about our long-term chances of taming HIV? Certainly there has been some off-message promotion of MMC, aimed at reeling in the young men, that could reinforce the impression that circumcision gives you freedom to ‘be a player’, says Prof. Catherine Burns (asso-

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IZINDABA

ciate professor of history based at the University of Pretoria and the university’s Centre for Sexualities, AIDS & Gender).

Cultural context

A factor that the US drivers of the Soka Uncobe campaign had not anticipated was that Swazi men were curious about the fate of their foreskins. ‘Early on in the campaign, rumours began circulating that the foreskins of men were going to be used to manufacture a cream that allowed people not to age,’ writes Mkhwanazi. ‘Other rumours had it that the foreskins were being used to spice up street food which when ingested would cause impotence. When the Swazi site managers reported these rumours in the weekly meetings comprised of the various implementing partners, they were told that such rumours were absurd and would in due time die down. They did not.’ Many of the ‘implementing partners’ in this case were young women from the USA, Mkhwanazi points out, who dismissed the on-the-ground reports as ‘superstition’. This speaks to the importance of understanding and being sensitive to the role social, cultural and even political context plays in how effective a campaign like MMC can be. ‘There’s a distinction between efficacy and effectiveness,’ says clinical psychologist Pierre Brouard, deputy director of the Centre for Sexualities, AIDS & Gender. In the real world, in the hurly-burly of a push to get as many circumcised as possible, are men getting the kind of careful messaging they were given in the three trials? ‘The nub of the matter is the extent to which they get all the messaging – for example, about not having sex again too soon.’ And that message has to be nested within the lived context – Brouard has anecdotal evidence of men who are concerned about adhering to that prescribed break from sexual intimacy, which allows their penis to heal fully, because of concerns that ‘if they don’t satisfy their partner, someone else will’, which means that counsellors need to address issues of intimacy between partners.

Missed opportunities

And are the medical follow-up figures quoted by Bailey et al.[3] as good as they sound, asks Burns. After all, even the high figures achieved at Asiphile mean that 1 300 men missed their first follow-up and 5 000 their second. ‘Medical follow-up is proving extremely expensive and complex to organise, to try and get people, who are diffusing across a whole landscape, for work, for school, for tertiary education, to get them to come back for follow-ups […] has proven difficult for even the most motivated of programmes,’ she says. How much is MMC costing us overall? ‘At the average exchange rate for 2014 of ZAR10.83 = USD1, the unit cost at the 33 facilities was determined to be USD132 (ZAR1 431) per circumcision performed,’ and ‘Approximately USD14.2 million (ZAR154 million) – including funding from PEPFAR and other sources – was reported to have been spent on VMMC demand creation over the most recent 12-month period (January - December 2014).’[11] If we are spending that much, says Burns, you have to ask yourself why we are not also piggybacking on the opportunity to do ‘gender sensitivity training, training around condom use and genital healthcare, and strengthening ideas about male egalitarianism’ at the same time. Why are MMC campaigns targeted, in by far the majority of cases, at men of African origin, and not South African Indians, whites and other groups, asks Burns. It is central to all public health efforts that there should be no exceptions that dilute the impact. ‘People are constantly moving across “boundaries” in human sexuality,’ she points out. ‘If you specifically leave out certain population groups, what is that based on epidemiologically? You racialise at your peril.’

Traditions of masculinity

And do the campaign messages and counselling take into account different understandings of the meaning of MMC for masculinity? ‘It is currently estimated that 46.4% of all males over age 15 in South Africa have been circumcised, through either a traditional or a medical procedure. However, only 18.6% of males have been circumcised medically.’[11] More than half these SA men have therefore self-evidently been circumcised as a traditional practice, but, says Moeti, ‘it is not always certain that the kind of circumcision done in some traditional settings may be effective in reducing HIV transmission risks’. What price does it exact from communities to force them to take their boys to a mobile clinic or hospital for this procedure? ‘People will see this as ripping the heart out of something that’s very sacred,’ says Prof. Louise Vincent (Rhodes University), whose research is largely focused on critical sexualities and women's reproductive health studies. ‘What I’ve been arguing to the World Health Organization is that what we really need is for people to take the culture seriously and layer on to that the messages that we want to get across,’ she adds. There are social risks if it’s not tackled with some thought for meanings of masculinity: ‘… some Xhosa men reportedly direct stigma toward those undergoing MMC, arguing that circumcisions conducted in a clinic do not confer the status of manhood, unlike the tougher traditional version long practised by Xhosa pre-initiates.’[10] It seems intuitive to bring in the traditional ‘custodians of culture’, both in amaXhosa culture and in others across the country, to align VMMC protocols and messages with what they are doing, rather than vice versa. Whether it’s human papillomavirus vaccination, Pap smears or HIV testing, no countrywide medical campaign can afford to ignore the lived realities of the communities it reaches – and VMMC has all sorts of points of intersection with realities that are not purely physical and ‘medical’. Instead of dismissing questions about how the campaign is working as contrarian or denialist, it would surely make sense to beef up assessment, monitoring and accountability to ensure that we’re getting the best impact possible. Mandi Smallhorne Freelance journalist and writer, Johannesburg, South Africa mandiwrite@icon.co.za 1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2005;2(11):e298. https://doi.org/10.1371/journal.pmed.0020298 2. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 2007;369(9562):657-666. https://doi.org/10.1016/S0140-6736(07)60313-4 3. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized control trial. Lancet 2007;369(9562):643-656. https://doi.org/10.1016/S01406736(07)60312-2 4. Morris BJ, Bailey RC, Klausner JD, et al. Review: A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care 2012;24(12):1565-1575. https:// doi.org/10.1080/09540121.2012.661836 5. Schenker I, Westreich M. Voluntary medical male circumcision: A necessary surgical intervention in curbing HIV/AIDS. RCS Bull 2015;97(9):378-381. https://doi.org/10.1308/rcsbull.2015.378 6. AVERT. Understanding the barriers to circumcision in southern and eastern Africa. 25 October 2016. https://www.avert.org/news/understanding-barriers-circumcision-southern-and-eastern-africa (accessed 6 June 2017). 7. Medical Brief. PEPFAR commits USD24 million to accelerating MMC efforts in SA. 7 December 2016. http://www.medicalbrief.co.za/archives/pepfar-commits-24m-accelerating-mmc-efforts-sa/ (accessed 6 June 2017). 8. Department of Health, South Africa, and South African National AIDS Council. South African HIV and TB Investment Case – Summary Report Phase 1. March 2016. http://sanac.org.za/wp-content/ uploads/2016/03/1603-Summary-Report-LowRes-18-Mar.pdf (accessed 6 June 2017). 9. Irin News. Circumcision plans go awry in Swaziland. 13 May 2013. http://www.irinnews.org/ news/2013/05/13 (accessed 6 June 2017). 10. Mathew W. Cutting into perceptions: Investigating men’s understanding of protection – through medical male circumcision for HIV prevention, in Durban, KwaZulu-Natal. MSocSci dissertation. Durban: University of KwaZulu-Natal, November 2012. 11. Tchuenche M, Palmer E, Haté V, et al. The cost of voluntary medical male circumcision in South Africa. PLoS One 2016;11(10):e0160207. https://doi.org/10.1371/journal.pone.0160207

S Afr Med J 2017;107(7):552-553. DOI:10.7196/SAMJ.2017.v107i7.12653

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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GUEST EDITORIAL

Wilderness medicine in southern Africa

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As the cradle of humankind, southern Africa is considered by many to be the origin of the peripatetic human soul. From Africa, our species has explored and expanded to settle every continent and environment on the planet. The tip of the continent has long been associated with the ebb and flow of indigenous cultures, and also the first truly global explorers, offering safe harbours and supplies to the likes of Dias, Darwin, Drake and Da Gama. It was the ultimate point of departure for expeditions of the epic eras of Antarctic exploration, serving Cook and Scott, leading to South Africa (SA) becoming an original signatory member of the Antarctic Treaty. The natural beauty and wealth of wilderness environments to be found in SA have kindled a nation of outdoor enthusiasts, adventurers, sportsmen and women, and a strong ethos of exploration. Today, South Africans continue to drive exploration around the globe in the name of science, the environment and other good causes. Where adventurers have fared, they have been forced to have ‘first-hand encounters with the world … collide with the earth … and bear witness’. The inherent risks of adventure and exploration have called for medicine to follow the path of man into the wilderness, providing care far from civilisation, and learning from human physiology under duress. Initially the role of the enthusiastic amateur physician-adventurer, this has led to the development of the field of wilderness and expedition (or extreme) medicine. While the discipline has become well established in parts of the world (particularly Europe and North America), Africa has traditionally been seen as the site of expeditions, rather than a role-player in the field. However, the practical experience, breadth and depth of knowledge and skill of SA medical practitioners should not be discounted. Although glamorously exotic destinations such as the Poles and Himalayas are more traditionally associated with high-profile expeditions, more aspiring summiteers die each year on 5 895 metre-high Mount Kilimanjaro than 8 848 metre-high Mount Everest. The diversity of African wilderness environments and outdoor lifestyle culture places our medics in an ideal position to become leaders in the field, and efforts to provide more formal training and support for wilderness medicine in SA are underway. Wilderness and expedition medicine draws from a wide range of medical fields, yet defies easy classification. Traditionally, the type of wilderness environment has been used to group the knowledge and skills required. For instance, mountaineering expeditions require knowledge of high altitude physiology and illness, exposure injuries, and trauma care, whereas jungle expeditions require

an understanding of tropical illnesses, envenomation and the challenging care of minor injuries. Polar, marine, desert and disaster environments all carry further special considerations. There are areas of intersection and overlap with many medical fields, beginning with general practice and emergency medicine, but also spanning sports medicine, tropical hygiene and infectious disease, aviation and maritime medicine, and occupational health. Medical professionals are often drawn into wilderness medicine through a particular recreational interest in one field (e.g. dive medicine), but are united by a fascination for the insights brought by the interaction of adverse environments and human physiology, and the challenges of treating the effects of physiological derangement or injuries occurring in the environments themselves. The continual increase in recreational use of the wilderness by an ever-widening spectrum of South Africans is, unfortunately, parallelled by an increasing need for high-quality care in environments separated from normal medicine by extremes of distance, environment and terrain (Fig 1). In the spirit of growing the discipline in southern Africa, local enthusiasts and experts in the fields present this series of CME articles on wilderness medicine topics, with a focus on their relevance in the region. In this edition, the scope stretches from ocean to mountain, discussing the risks and management of high-altitude illnesses,[1] an update on drowning in SA,[2] and the management of cold-exposure injuries.[3] A further edition in the series will address expedition medicine, psychological and human factors, and heat-related illness. Finally, we introduce the fledgling Wilderness and Expedition Medicine Society of Southern Africa, formed to create a home and hub for interested practitioners around the country. It is our fervent hope that these efforts will enable a new generation of African wilderness medics to have first-hand encounters with the world, and be changed for the better.

Incidents, n

Adventure is a path. Real adventure – self-determined, selfmotivated, often risky – forces you to have first-hand encounters with the world. The world the way it is, not the way you imagine it. Your body will collide with the earth and you will bear witness. In this way you will be compelled to grapple with the limitless kindness and bottomless cruelty of mankind – and perhaps realize that you yourself are capable of both. This will change you. Nothing will ever again be black-and-white. (The Ghost Road – Mark Jenkins)

Year

Fig. 1. Cumulative wilderness rescue statistics from 1900 to early 2017, courtesy of the SA Mountain Accidents Database.

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Rik De Decker Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, and Red Cross War Memorial Children’s Hospital, Cape Town, South Africa

Ross Hofmeyr Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town; and WildMedix, Cape Town, South Africa ross.hofmeyr@uct.ac.za

1. Hofmeyr R, Tölken G, De Decker R. Acute high-altitude illness. S Afr Med J 2017;107(7):556-561. https://doi.org/10.7196/SAMJ.2017.v107i7.12612 2. Matthew J, Robertson C, Hofmeyr R. Update on drowning. S Afr Med J 2017;107(7):562-565. https:// doi.org/10.7196/SAMJ.2017.v107i7.12609 3. Hofmeyr R. Wilderness cold-exposure injuries: An African Perspective. S Afr Med J 2017;107(7):566570. https://doi.org/10.7196/SAMJ.2017.v107i7.12610

Jay Matthew Department of Emergency Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban; and Lifesaving South Africa, Durban, South Africa

S Afr Med J 2017;107(7):554-555. DOI:10.7196/SAMJ.2017.v107i7.12608

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

CME

Acute high-altitude illness R Hofmeyr,1,2 MB ChB, DipPEC, DA, MMed (Anaes), FCA, FAWM; G Tölken,2,3 MA, STB; R De Decker,4 MSc, MB ChB, DCH (UK), FCPaeds (SA), Cert Med Genetics (Paeds) Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, South Africa WildMedix, Cape Town, South Africa 3 Mountain Rescue, Hottentots-Holland Section – Mountain Club of South Africa, Cape Town, South Africa 4 Department of Paediatrics and Child Health, University of Cape Town and Red Cross War Memorial Children’s Hospital, Cape Town, South Africa 1 2

Corresponding author: R Hofmeyr (ross.hofmeyr@uct.ac.za)

A substantial proportion of South Africa (SA)’s population lives at high altitude (>1 500 m), and many travel to very high altitudes (>3 500 m) for tourism, business, recreation or religious pilgrimages every year. Despite this, knowledge of acute altitude illnesses is poor among SA doctors. At altitude, the decreasing ambient pressure proportionally decreases available oxygen (hypobaric hypoxia). This triggers both immediate respiratory compensation and gradual acclimatisation that occurs over days to weeks. Rapid ascents to altitudes above 2 500 m can precipitate acute altitude illness, including acute mountain sickness (AMS) and high-altitude pulmonary and cerebral oedema (HAPE and HACE). The best preventive measure is gradual ascent (no more than 300 - 500 m increase in sleeping altitude per day, with additional rest days for acclimatisation for every 1 000 m altitude gain), although chemoprophylaxis may speed acclimatisation. In the field, AMS, HAPE and HACE are diagnosed clinically. The Lake Louise Score questionnaire is used to elicit symptoms of AMS, and can be supplemented by assessing clinical signs such as tachycardia, tachypnoea, crepitations or ronchi, and ataxia. The mainstay of treatment for all but mild AMS is rapid descent to lower altitudes, which can be facilitated by administration of oxygen and drugs, including acetazolamide, dexamethasone and nifedipine, or use of a portable hyperbaric chamber. S Afr J Med 2017;107(7):556-561. DOI:10.7196/SAMJ.2017.v107i7.12612

Scenario

Mr X – a fit and healthy 30-year-old man – joins a group climbing Mount Kilimanjaro, hoping to reach Uhuru Peak (5 895 m above mean sea level). His 6-day, 5-night expedition is following the Rongai route, approaching from the northern side of Kilimanjaro. After flying in from his home at sea level in South Africa (SA), they begin their trek near the Kenyan border at 1 900 m. Despite no previous experience at altitude, he shows no signs of struggling with the ascent, and easily copes during the deliberately slow hikes of the first 3 days to reach Kikelewa Caves (3 675 m). However, on arrival at Mawenzi Tarn camp (4 300 m) at the end of the hot 4th day, Mr X complains of a headache, dizziness and nausea. The local lead guide offers Mr X 800 mg oral ibuprofen to ease the headache and encourages him to rest. Having no appetite, Mr X skips dinner that night, but does take care to remain well hydrated. In the morning his headache has resolved, but he complains of having had fitful sleep. Routine screening by the guides shows elevated resting breathing and heart rates (respiratory rate 28/min.; heart rate 120/ min.). A portable fingertip pulse oximeter shows that his peripheral arterial oxygen saturation (SpO2) has dropped to 64%. The guides are nevertheless anxious to push on, and Mr X continues with the group to Kibo Huts (4 714 m). During the day, his headache returns, and he feels lethargic and breathless. Nonetheless, with his bucket-list goal in sight, he participates in the final summit preparations. The group leaves camp for the summit at midnight. During the relentless climb to the crater rim (5 680 m), Mr X feels increasingly cold, and develops ataxia and tunnel vision. Amid the tired party in the predawn light, his deterioration remains unnoticed. At Gilman’s Point on the summit ridge, the group stops for a brief rest. Mr X is disorientated, has lost fine motor control, and speaks incoherently before he collapses.

By this point, the guides have discovered that you are a doctor, and turn to you for help. What is your assessment and action plan? Thinking back, if you were the expedition’s doctor, would you have intervened earlier?

Background

Although SA is not traditionally associated with high-altitude climbing, the country is blessed with many beautiful mountain ranges. An increasingly substantial proportion of the population takes part in recreational climbing and mountaineering, both locally and abroad. Many also travel to high-altitude regions worldwide for simple tourism, business or religious pilgrimages.[1] Globally, it has been estimated that >35 million people travel to altitudes of greater than 3 000 m per annum.[2] In southern Africa, several large metropolitan areas are above 1 500 m, and peaks of up to 3 482 m are regularly ascended. Despite this, there is generally a poor level of recognition of the implications and risks of high altitude for healthy travel and recreation among SA doctors.[3] High altitude is defined as greater than 1 500 m above sea level. At this level, the physiological implications of decreasing ambient pressure (hypobaria) and corresponding decrease in the partial pressure of oxygen (hypoxia) are regularly apparent, although they do not have pathological consequences in healthy individuals. Altitude between 1 500 m and 3 500 m is referred to by some authors as intermediate, and it is within this range that altitude-related illnesses begin to manifest. Very high altitude is defined as being above 3 500 m, where simple physiological compensation is no longer sufficient to maintain oxygenation, and gradual acclimatisation is required. Exposure to extreme altitudes (above 5 500 m) without acclimatisation is highly likely to cause severe illness. The summit of Kilimanjaro (5 895 m) has an ambient pressure of approximately 47 kPa (less than half of

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sea-level pressure), resulting in arterial oxygen tension (PaO2) of only 6 kPa, even with ideal acclimatisation (Fig. 1). Blood gases drawn near the summit of Mount Everest have demonstrated the lowest recorded oxygen partial pressures in healthy subjects, with a PaO2 range of 2.55 - 3.93 kPa.[4]

Acute high-altitude illnesses

Physiology of altitude, acclimatisation and aetiology of high-altitude illnesses

The complex physiological response to altitude is not yet fully understood and beyond the scope of this article. While the concentration (proportion) of oxygen in the atmosphere remains remarkably consistent at 20.9%, the drop in ambient pressure with increasing altitude results in a directly corresponding decline in the partial pressure (PO2). The reduction in inspired PO2 is compounded by the unaltered saturated vapour pressure of water in the alveoli, and the unaltered (or increased) metabolic production of carbon dioxide. Although rapid and profound compensation through increased minute ventilation is possible, the inevitable physiological consequence of ascent to high altitude is hypobaric hypoxia.[5] Over time, the combination of hypoxia and hyperventilation-induced respiratory alkalosis triggers a cascade of physiological effects, leading to acclimatisation. These include increased renal excretion of bicarbonate, a 2-3-DPG-mediated shift in the oxygen-haemoglobin dissociation curve, erythropoiesis, and angioneogenesis at the capillary level. Over a period of days to weeks, the body gradually adjusts to optimise oxygen delivery to the tissues, maintaining the oxygen cascade from atmosphere to mitochondrion. Indeed, given sufficient time to acclimatise, the human organism is remarkably capable of function despite low PaO2, as is eloquently demonstrated by a visit to any paediatric cardiology ward, where children with cyanotic congenital heart disease play alongside their well-oxygenated counterparts. However, a sudden decrease in PaO2 without adequate time for acclimatisation is highly likely to manifest as acute illness. In Metres above sea level

9 000

Alveolar partial pressure of oxygen (kPa)

Minimum ascent rate (days)

Extreme altitude

8 000

Aconcagua 6 961 m

7 000

Very high altitude

6 000 Kilimanjaro 5 895 m 5 000

Mont Blanc 4 808 m

4 000

High altitude

Thabana Ntlenyana 3 482 m 3 000 Drakensberg 3 000 m 2 000

1 000

Sea level

Johannesburg 1 760 m

Table Mountain 1 084 m

11 13

Fig. 1. Altitudes of well-known peaks and African locations, with the approximate alveolar partial pressure of oxygen and minimum duration of safe acclimatisation (SAMJ,[3] with permission).

Acute mountain sickness, high-altitude cerebral oedema and high-altitude pulmonary oedema

Altitude illness is characterised by tissue hypoxia and oedema, particularly in the brain and lungs. This is the result of a complex interplay of hydrostatic pressure differences due to hypoxic vasomotor changes, and increased capillary permeability through release of agents such as vascular endothelial growth factor and hypoxia-inducible factor 1-alpha (HIF-1-α). The predominant symptom complex includes headaches, nausea and loss of appetite, dizziness or lightheadedness, fatigue or weakness, and sleep disturbance. It is diagnosed clinically, because of the typical lack of advanced investigations in the context of high-altitude expeditions and the multifactorial nature of the disease (see ‘Clinical diagnosis’ below). Similarly, high-altitude pulmonary oedema (HAPE) and high-altitude cerebral oedema (HACE) are commonly considered advanced forms of AMS and diagnosed on clinical signs, but can and do occur independently. Onset of altitude-related illness is indiscriminate, and can occur at relatively low altitudes (instances of AMS have been reported at as low as 2 000 - 2 500 m), but is most common after rapid ascent to above 3 500 m. Prior safe ascent to altitude is no guarantee of avoiding AMS on subsequent exposure.[8] Physical fitness, gender and youth are not reliably predictive, although there is a protective association with increased age. A genetic predisposition is being researched.[10-12] Typical altitudes for onset of development of HAPE and HACE are 3 000 m and 4 500 m, respectively. While AMS is usually diagnosed within a day of reaching a new elevation, HAPE and HACE (considered to be advanced manifestations or complications of AMS) commonly present after more than 24 hours at altitude.[6,13,14]

Prevention of high-altitude illness

Everest 8 848 m

the context of ascent to altitude, simple respiratory compensation is no longer sufficient from ~3 500 m. This explains the sudden increase in high-altitude illnesses (HAIs) and particularly acute mountain sickness (AMS) seen above this point (Table 1). The exact aetiology of AMS, widely considered a precursor to more severe altitude illnesses, is also poorly understood.[6-9]

AMS, HACE and HAPE are the most commonly encountered altitudeinduced illnesses during ascent above 2 500 m, but are also nearly entirely preventable.[6,7] Up to altitudes of 6 000 m, the occurrence of HAI is the direct result of inadequate acclimatisation. Depending on individual physiology and ascent profile, up to 70% of mountaineers develop symptoms of AMS.[14] The foremost approach to AMS, HAPE and HACE is prevention through education, supporting conservative ascent profiles to allow sufficient acclimatisation, and promoting adequate hydration, caloric intake and exposure protection.[3,14] Within the African context, AMS is very prevalent on Kilimanjaro owing to the lack of a sufficiently long approach trek and rapid ascent profiles followed by local tour operators.[15] Kilimanjaro climbs of <7 days’ duration are therefore considered ‘high risk’ profiles (Table 2), which contribute to the 3 - 8 reported but avoidable deaths out of about 30 000 trekkers on the mountain each year.[3,13,15-19] The single most effective method of prevention is gradual acclimatisation, paired with adequate hydration and caloric intake. After reaching an elevation of 2 500 - 3 000 m, sleeping altitudes should not increase by more than 300 - 500 m each day, with a rest day at the same altitude for each 1 000 m ascent.[3,13,14] Sleeping elevation contributes more significantly to adequate acclimatisation than physical exercise and altitude gain during the day.[13] Where terrain necessitates occasional elevation gains in excess of suggested safe ascent

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Table 1. Consequences of acute exposure to high altitude High altitude (1 500 - 3 500 m)

Very high altitude (3 500 - 5 500 m)

Extreme altitude (5 500 - 8 850 m)

HAI occurs with rapid ascent above 2 500 m

Most common range for HAI (AMS, HAPE, HACE)

Abrupt ascent always causes severe HAI

↓Exercise performance ↑Ventilation

Requires acclimatisation for physical effort to be tolerated

Progressive physiological deterioration outstrips acclimatisation

Minor decrease in SpO2 (usually ≥90%)

SpO2: 75 - 85%

SpO2: 55 - 75% Severe hypocarbia

PaO2: 7 - 10 kPa

PaO2: 5 - 8 kPa

PaO2: 3.5 - 5 kPa

Severe hypoxia unlikely in the Extreme hypoxia may occur Always requires absence of underlying illness during sleep, exercise or illness acclimatisation to avoid illness or HAPE HAI = high-altitude illness; AMS = acute mountain sickness; HAPE = high-altitude pulmonary oedema; HACE = high-altitude cerebral oedema.

Table 2. Risk categories for AMS (Wilderness Medical Society consensus guidelines)[13] Risk category

Description

Low

Individuals with no prior history of altitude illness and ascending to ≤2 800 m Individuals taking ≥2 days to arrive at 2 500 - 3 000 m with subsequent increases in sleeping elevation <500 m/day and an extra day for acclimatisation every 1 000 m

Moderate

Individuals with a prior history of AMS and ascending to 2 500 - 2 800 m in 1 day No history of AMS and ascending to >2 800 m in 1 day All individuals ascending >500 m/day (increase in sleeping elevation) at altitudes >3 000 m but with an extra day for acclimatisation every 1 000 m

High

Individuals with a history of AMS and ascending to >2 800 m in 1 day All individuals with a prior history of HACE All individuals ascending to >3 500 m in 1 day All individuals ascending >500 m/day (increase in sleeping elevation) >3 000 m without extra days for acclimatisation Very rapid ascents (e.g. <7 day ascents of Mount Kilimanjaro)

AMS = acute mountain sickness; HACE = high-altitude cerebral oedema. Altitudes refer to the altitude at which the person sleeps; ascent is assumed to start from elevations <1 200 m; risk categories pertain to unacclimatised individuals.

profiles, additional rest days must be incorporated into the itinerary to keep the average rate of ascent within safe parameters.[13] Adequate hydration (estimated in the field by maintaining frequent micturition and keeping urine colourless) is imperative to allow the elimination of bicarbonate necessary for physiological acclimatisation. Although loss of appetite is a common feature, care should be taken to consume sufficient carbohydrate-rich meals to compensate for increased metabolic loads and improve the respiratory exchange ratio.[5] Minimising loss of body fat has the benefit of helping cope with low temperatures at high altitude; a more significant risk of poor nutrition is subsequent loss of muscle mass.

Clinical diagnosis: Symptoms and the Lake Louise symptom score

Secondary only to proper acclimatisation, early recognition of AMS is key to allowing individuals to take simple corrective measures before the risks of complications increase. AMS is defined by the presence of a highaltitude headache (onset of headache within 24 hours of ascent to above 2 500 m) and at least one other symptom of sleep disorder, gastrointestinal upset (nausea, vomiting or loss of appetite), dizziness or lightheadedness, and lethargy, fatigue or weakness. Frequently, this is accompanied by peripheral oedema, shortness of breath and tachycardia, which often worsen at night.[8,14,20] Being

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nonspecific, these symptoms are often mistaken for non-consequential ailments such as flu, a cold or dehydration – all common travel complaints.[6] However, AMS should always be assumed until proven otherwise.[3] Although the diagnosis of AMS is symptomatic and clinical, determining its severity is largely subjective. As participants focus on expedition goals, symptoms are often under-reported, which leads to an underestimation of severity. This can result in a lack of appropriate medical intervention, such as the climber being advised to discontinue an ascent. Furthermore, under-reporting of AMS symptoms such as severe headaches and drowsiness may lead to the early warning signs of HACE being missed. To objectively standardise diagnosis and quantify the severity of AMS, the Lake Louise Symptom Questionnaire and Clinical Scores were established (LLSQ and LLS-C, respectively). This allows for both monitoring of symptoms by lay mountaineers, and field research of AMS by expedition doctors (Fig. 2).[13,20,21] Each of the five symptoms and three clinical signs are assigned a severityrelated score from 0 (absent) to 3 (severe or incapacitating). Inability to stand for an ataxia test carries a score of 4. AMS is considered present with a score of ≥3 for the LLSQ, and >5 for the LLS-C. It is advisable that the LLSQ is performed twice daily by team members (in the mornings after waking, and in the evenings once settled into camp), and the LLS-C independently by the team physician. For HAPE, AMS symptoms are typically aggravated by dyspnoea at rest or with light workloads, impaired exercise performance, coughing, tachycardia, subjective chest tightness, ronchi/rales, cyanosis, mild fever and (in extreme cases) foamy bloodstained sputum.[7,14,22] Importantly, HAPE may occur without the precedence of AMS symptoms.[23] HACE commonly presents with severe headaches that remain unresponsive to analgesics, ataxia, altered level of consciousness and loss of insight. A simple field test for ataxia is to observe an individual walking heel-to-toe on a straight line drawn on the ground.[14,24] Complications of AMS in the form of HAPE or HACE may be lethal, and early clinical recognition is vital in austere environments to allow suitable and effective treatment. Research into the use of point-ofcare ultrasound scans of the lung and optic nerve sheath diameter is a promising new modality for screening, prediction and early diagnosis of HAPE and HACE respectively, but is still at the experimental stage.[25,26]

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AMS

HACE

Increase in altitude above 2 500 m in last 4 days AND headache plus at least one other symptom

AMS with ataxia OR decreased LOC

Headache

None

Mild

Moderate

Gastrointestinal tract Fatigue/ weakness

None

weakness

Score

Dizziness Sleep Symptoms alone:

Clinical

Mental status Ataxia (heel-toe)

Poor appetite Nausea and/or or mild nausea vomiting

None

Mild

Moderate

None

Mild

Moderate

Normal

Not as good as usual

Woke many times

≥3 = mild AMS Normal None

4 - 5 = moderate AMS

Severe/ incapacitating Severe/ incapacitating Severe/ incapacitating Severe/ incapacitating

Ataxia AND decreased LOC in absence of AMS

HAPE Clinical diagnosis ( ≥2 symptoms AND ≥2 signs)

Unable to sleep

None

One location

Signs

Dyspnoea at rest

Crackles or wheezing in ≥1 lung ﬁeld

Cough

Central cyanosis

≥6 = severe AMS

Lethargy/ Disorientated/ Diﬃcult to rouse/ lassitude confused unconscious Manoeuvres to Steps oﬀ line Falls down balance

Weakness and/or ↓exercise performance Chest tightness or congestion

Patient unable to stand for ataxia test = 4 Peripheral oedema

Symptoms

≥2 locations

Tachypnoea Tachycardia

Gr 1 (mild): only symptoms with exertion; no limitation of function

Gr 2 (moderate): ambulant, but limited. Rales may be present

Gr 3 (serious): symptoms at rest, ± confused. Rales,↑HR ↑RR

Gr 4 (severe): comatose or obtunded. Frank oedema

Symptoms + clincal score: ≥5 = AMS Fig. 2. Diagnostic criteria for acute HAI, incorporating the Lake Louise Symptom and Clinical Scores. Graphic representation from WildMedix Mountain Expedition Medicine course materials, used with permission. (AMS = acute mountain sickness; HAPE = high-altitude pulmonary oedema; HACE = high-altitude cerebral oedema; Gr = grade; LOC = level of consciousness; HR = heart rate; RR = respiratory rate.)

Chemoprophylaxis

Although widely advised, the prophylactic intake of the carbonic anhydrase inhibitor acetazolamide (Diamox 125 - 250 mg twice daily) is debated in the literature.[2,13,27] By increasing renal bicarbonate excretion, it can improve the rate of acclimatisation, but has limited or no effect if the ascent profile is too rapid.[7,14,19,28] Acetazolamide can result in side-effects that mimic AMS (nausea, vomiting, anorexia and dizziness) and blurred vision, severe paraesthesia and odd tastes in the mouth. Individuals wishing to take acetazolamide for high-risk ascent profiles should ideally take several test doses at home before the ascent. It is contraindicated for use in diabetes and sulphonamide allergy.[13,14] Use of dexamethasone as prophylaxis (2 mg 6-hourly or 4 mg 12-hourly) is similarly debated, mainly because of concerns regarding masking symptoms of AMS, and its side-effect profile.[13,28] However, it is used selectively in groups making very short rapid high-altitude ascents, such as rescue teams. Ibuprofen has been shown in randomised controlled trials to be more effective than placebo in decreasing the incidence of AMS, but this has been contested in light of the fact that it reduces headache, which is essential for the clinical diagnosis.[29,30] Alternative prophylactic substances such as ginkgo bilo-

ba and coca-derived products have shown contradictory results.[13,29,31] Individuals at elevated risk or with previous episodes of HAPE can be treated with nifedipine (20 mg slow-release preparation 8-hourly) or sildenafil (20 - 50 mg 8-hourly) prophylactically. As both drugs can cause

Headache

+ symptoms

AMS

Stop ascent Analgesia Fluids

Field management

For mild to moderate symptoms of AMS (LLSQ 3 - 5 or LLS-C >5), primary treatment takes the form of rest days without any

+ ataxia or LOC

Mild-moderate (LLS 3 - 5)

Analgesics Exclude other causes

postural hypotension, a trial at home before departure is recommended.

Severe (LLS ≥6)

HACE

HAPE

Prepare descent

Sit upright Nifedipine 30 mg q 12 h ± sildenafil 50 mg q 8 h

Prepare descent Analgesia Fluids

DMZ 8 mg then 4 mg q 6 h ± ACZ 250 mg q 12 h

Hyperbaric chamber Oxygen if availabe

Descend when able

Fig. 3. Flow diagram for the management of acute high-altitude illness (adapted from Davis et al.[35]). (AMS = acute mountain sickness; LOC = level of consciousness; DMZ = dexamethasone (first dose intravenously then intramuscularly); ACZ = oral acetazolamide; nifedipine = sustained-release; HAPE = high-altitude pulmonary oedema; HACE = high-altitude cerebral oedema; LLS = Lake Louise Score.)

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physical exertion at the current altitude, until all symptoms resolve[13] (Fig. 3). Additional supportive treatment with oral anti-emetics, simple analgesia, adequate hydration and sleeping with a slightly elevated upper body are effective. If symptoms do not improve within 24 hours, the patient should descend to an altitude where the symptoms are not present. Acetazolamide (250 mg orally twice daily) may be administered (particularly if symptoms worsen and descent is delayed).[13] Should the presenting altitude be situated in a ‘terrain trap’ – a location which demands some ascent before descent can be commenced – then early descent before exacerbation of symptoms must be considered. Once symptoms have progressed further, a terrain trap may preclude descent, leading to a serious or fatal outcome. Other scenarios that may hamper immediate descent – worsening weather, other injuries or difficult terrain – deserve the same considerations. In the presence of severe symptoms (LLSQ score >5), HACE should be suspected and integrated into the treatment plan.[3] Immediate action takes the form of refraining from any further ascent, administration of oxygen if available, enforced rest and protection against cold. Descent by any safe means should be initiated. Supporting treatment as described may be provided. Dexamethasone should be considered in severe AMS and used in all cases of HACE (8 mg orally every 6 hours, or 4 mg intramuscularly/intravenously every 4 hours).[13,14] As soon as the patient’s condition allows

(able to safely navigate the terrain), descent must be started, going down to the altitude at which the patient was last completely well, or if that altitude is unknown, at least 500 - 1 000 m.[6,28,32] Descent should avoid terrain traps and the patient should not carry any loads. If descent is delayed because of environmental conditions, a portable hyperbaric chamber (PHC) is strongly advised.[3,14] A PHC is an inflatable, lightweight, airtight capsule into which a patient is placed while the capsule is inflated by a foot pump to increase the internal pressure, simulating descent (Fig. 4). Pumping must be continuous to maintain air flow, making the use of a PHC extremely strenuous at high altitude. PHC treatment is to be continued for 2 - 4 hours to stabilise severely ill patients before descending.[24,33] PHCs are rare in the African context, but are carried by some high-altitude expeditions. For HAPE patients, immediate rest (with the upper body elevated), protection against cold, supplementary O2, acetazolamide and dexamethasone followed by slow-release nifedipine (20 mg orally) are recommended. This can be supplemented with sildenafil (50 mg orally) and inhaled salbutamol or salmeterol, which improves pulmonary interstitial oedema by stimulating the sodium/potassium pump. Antidiuretics should be avoided, and use of a PHC should be considered, if available. All patients with severe AMS, HAPE or HACE should be evacuated to lower altitudes, preferably by passive evacuation using a stretcher, beast of burden or heli-

Fig. 4. The authors training expedition doctors and mountain guides discussing the use of a portable hyperbaric chamber at 4 800 m on Kilimanjaro (photo: Dr Chanèl Rossouw, with permission).

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copter. Adequate treatment equipment must accompany the patient during descent. The patient must be continuously monitored for deterioration, and must be safely managed and assisted in navigating the terrain once ambulant. This task should be performed by adequately trained and equipped medical personnel, rather than being deferred to guides or porters. Re-ascent should not be considered until patients are completely asymptomatic after cessation of treatment.[13] Should it be difficult to differentiate between AMS, HAPE and HACE, treat for all three conditions. However, care must be taken in HACE to not inadvertently lower mean arterial pressure by using nifedipine, which could worsen cerebral oxygenation by lowering cerebral perfusion pressure.[8,33,34]

Scenario resolution

Faced with Mr X’s collapse on the summit ridge, you regret not speaking up at Mawenzi Tarn, 1 500 m below, although the differential diagnosis for his symptoms at that stage was broad, including simple dehydration or heat stroke. You recognise that the combination of headache, loss of appetite and poor sleep already constituted a clinical diagnosis of mild AMS. At Kibo, his breathlessness and lethargy should have alerted the expedition leadership that he should descend, or at least commence treatment for AMS. In the setting of his acute collapse, you recognise that the differential includes exhaustion, hypothermia, hypoglycaemia, dehydration and various other medical conditions, but a presumptive diagnosis of severe AMS and high-altitude cerebral oedema must be made. Knowing that only the most rudimentary field rescue facilities and no helicopter are available, which will undoubtedly delay definitive medical care, you urgently administer doses of oral acetazolamide and intravenous dexamethasone as well as supplemental oxygen from the guide’s cylinder, and initiate a rapid descent. Foregoing the summit, you monitor his condition on an ongoing basis. By the time Mr X reaches Kibo he is able to walk unaided, and you push on down to Horombo Huts (3 700 m). Other than tiredness and a slight cough, Mr X is feeling well. He thanks you for sacrificing your summit bid to assist him and affirms his intention to return to the mountain again with a more prudent acclimatisation profile. 1. Basnyat B. High altitude pilgrimage medicine. High Alt Med Biol 2014;15(4):434-439. http://dx.doi.org/10.1089/ham.2014.1088 2. Berghold F. Drug abuse in the mountains. In: Vsicor G, Ricart A, Leal C, eds. Health and Height: Proceedings of the 5th World Congress on Mountain Medicine and High Altitude Physiology. Barcelona: Univarsitat de Barcelona, 2003:99-106.

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3. Hofmeyr R, Meyer W, James M, De Decker R. Recognising and mitigating the risk of altitude-related illness. S Afr Med J 2016;106(9):834-835. http://dx.doi.org/10.7196/SAMJ.2016.v106i9.11389 4. Grocott MP, Martin DS, Levett DZ, et al. Arterial blood gases and oxygen content in climbers on Mount Everest. N Engl J Med 2009;360(2):140-149. http://dx.doi.org/10.1056/NEJMoa0801581 5. West JB. Acclimatization and tolerance to extreme altitude. J Wilderness Med 1993;4(1):17-26. 6. Johnson C, Anderson S, Dallimore J, et al. Oxford Handbook of Expedition and Wilderness Medicine. 2nd ed. Oxford: Oxford University Press, 2015. 7. Gallagher SA, Hackett PH. High-altitude illness. Emerg Med Clin North Am 2004;22(2):329-355. http://dx.doi.org/10.1016/j.emc.2004.02.001 8. Hackett PH, Roach RC. High-altitude illness. N Engl J Med 2001;345(2):107-114. http://dx.doi.org/10.1056/NEJM200107123450206 9. Bailey DM, Willie CK, Hoiland RL, et al. Surviving without oxygen: How low can the human brain go? High Alt Med Biol 2016;18(1):73-79. http://dx.doi.org/10.1089/ham.2016.0081 10. MacInnis MJ, Koehle MS, Rupert JL. Evidence for a genetic basis for altitude illness: 2010 update. High Alt Med Biol 2010;11(4):349-368. http://dx.doi.org/10.1089/ham.2010.1030 11. MacInnis MJ, Rupert JL. â&#x20AC;&#x2122;Ome on the range: Altitude adaptation, positive selection, and Himalayan genomics. High Alt Med Biol 2011;12(2):133-139. http://dx.doi.org/10.1089/ham.2010.1090 12. MacInnis MJ, Widmer N, Timulsina U, et al. A preliminary genome-wide association study of acute mountain sickness susceptibility in a group of Nepalese pilgrims ascending to 4380 m. High Alt Med Biol 2015;16(4):290-297. http://dx.doi.org/10.1089/ham.2015.0065 13. Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness: 2014 update. Wilderness Environ Med 2014;25(Suppl 4):S4-S14. http://dx.doi.org/10.1016/j.wem.2014.06.017 14. KĂźpper T, Gieseler U, Angeline C, et al. Consensus Statement of the Union Internationale des Associations d'Alpinisme Medical Commission. Vol. 2. Emergency Field Management of Acute Mountain Sickness, High Altitude Pulmonary Edema, and High Altitude Cerebral Edema. Berne: UIAA, 2012. 15. Shah NM, Windsor JS, Meijer H, Hillebrandt D. Are UK commercial expeditions complying with wilderness medical society guidelines on ascent rates to altitude? J Travel Med 2011;18(3):214-216. http:// dx.doi.org/10.1111/j.1708-8305.2011.00511.x 16. Karinen H, Peltonen J, Tikkanen H. Prevalence of acute mountain sickness among Finnish trekkers on Mount Kilimanjaro, Tanzania: An observational study. High Alt Med Biol 2008;9(4):301-306. http:// dx.doi.org/10.1089/ham.2008.1008 17. Jackson SJ, Varley J, Sellers C, et al. Incidence and predictors of acute mountain sickness among trekkers on Mount Kilimanjaro. High Alt Med Biol 2010;11(3):217-222. http://dx.doi.org/10.1089/ham.2010.1003 18. Davies AJ, Kalson NS, Stokes S, et al. Determinants of summiting success and acute mountain sickness on Mt Kilimanjaro (5 895 m). Wilderness Environ Med 2009;20(4):311-317. http://dx.doi. org/10.1580/1080-6032-020.004.0311 19. Nicol LG, Evans HE. Walk high, sleep low: An observational cohort study of altitude symptoms and physiological profiles over a 6 day ascent of Mount Kilimanjaro. Wilderness Environ Med 2014;25(3):354. http://dx.doi.org/10.1016/j.wem.2014.01.010

20. Roach R, Bartsch P, Oelz O, Hackett PH. The Lake Louise acute mountain sickness scoring system. In: Sutton JR, Houston CS, Coates G, eds. Hypoxia and Molecular Medicine. Burlington, USA: Queen City Printers, 1993:272-274. 21. Consensus Committee, International Hypoxia Symposium. The Lake Louise Consensus on the Definition and Quantification of Altitude Illness. In: Sutton J, Houston CS, Coates G, eds. Hypoxia and Mountain Medicine. Burlington, USA: Queen City Printers, 1992:327-330. 22. McIntosh SE, Leemon D, Visitacion J, Schimelpfenig T, Fosnocht D. Medical incidents and evacuations on wilderness expeditions. Wilderness Environ Med 2007;18(4):298-304. http://dx.doi. org/10.1580/07-WEME-OR-093R1.1 23. High Altitude Pulmonary Edema (HAPE). International Society for Mountain Medicine. 2016. http:// ismm.org/index.php/high-altitude-pulmonary-edema.html (accessed 9 April 2017). 24. Schimelpfenig T. NOLS Wilderness Medicine. Mechanicsburg, USA: National Outdoor Leadership School and Stackpole Books, 2000. 25. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris NS. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest 2007;131(4):1013-1018. http:// dx.doi.org/10.1378/chest.06-1864 26. Willmann G, Gekeler F, Schommer K, et al. Update on high altitude cerebral edema including recent work on the eye. High Alt Med Biol 2014;15(2):112-122. http://dx.doi.org/10.1089/ham.2013.1142 27. Luks AM. Which medications are safe and effective for improving sleep at high altitude? High Alt Med Biol 2008;9(3):195-198. http://dx.doi.org/10.1089/ham.2008.1025 28. International Society for Mountain Medicine. Treating acute mountain sickness. 2016. http://ismm. org/index.php/treating-ams.html (accessed 9 April 2017). 29. Gertsch JH, Lipman GS, Holck PS, et al. Prospective, double-blind, randomized, placebo-controlled comparison of acetazolamide versus ibuprofen for prophylaxis against high altitude headache: The headache evaluation at altitude trial (HEAT). Wilderness Environ Med 2010;21(3):236-243. http:// dx.doi.org/10.1016/j.wem.2010.06.009 30. Lipman GS, Eifling KP, Ellis MA, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of heat-related illness: 2014 update. Wilderness Environ Med 2014;25( Suppl 4):S55-S65. http://dx.doi.org/10.1016/j.wem.2014.07.017 31. Pandit A, Karmacharya P, Pathak R, Giri S, Aryal MR. Efficacy of NSAIDs for the prevention of acute mountain sickness: A systematic review and meta-analysis. J Community Hosp Intern Med Perspect 2014;4(4). http://dx.doi.org/10.3402/jchimp.v4.24927 32. International Society for Mountain Medicine. High altitude cerebral edema (HACE). 2016. http:// ismm.org/index.php/high-altitude-cerebral-edema (accessed 9 April 2017). 33. Stream JO, Grissom CK. Update on high-altitude pulmonary edema: Pathogenesis, prevention, and treatment. Wilderness Environ Med 2008;19(4):293-303. http://dx.doi.org/10.1580/07-WEME-REV-173.1 34. Zafren K. Prevention of high altitude illness. Travel Med Infect Dis 2014;12(1):29-39. http://dx.doi. org/10.1016/j.tmaid.2013.12.002. 35. Davis PR, Pattinson KT, Mason NP, Richards P, Hillebrandt D. High altitude illness. J R Army Med Corps 2005;151(4):243-249.

Update on drowning This open-access article is distributed under CC-BY-NC 4.0.

J Matthew,1 BSc, MB ChB, DipPEC (SA), FAWM; C Robertson,2 MB ChB, FCEM; R Hofmeyr,3 MB ChB, DipPEC (SA), MMed (Anaes), FCA(SA), FAWM

Department of Emergency Medicine, Faculty of Health Sciences,University of KwaZulu-Natal, Durban; and Lifesaving South Africa, Durban, South Africa National Sea Rescue Institute, Cape Town, South Africa 3 Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town; and WildMedix, Cape Town, South Africa 1 2

Corresponding author: J Matthew (rapid.sequence@yahoo.com)

Drowning is defined as the process of experiencing respiratory impairment from either submersion or immersion in liquid. Drowning morbidity and mortality are an under-recognised public health burden in southern Africa. Continuous concerted efforts are underway to improve awareness among recreational water users, but the prevention and management of drowning remain difficult to achieve owing to poor reporting and limited resources. Priorities for both prehospital and emergency department management of drowning victims include ensuring airway patency, adequate ventilation, supplemental oxygenation and rewarming for a pulsatile patient, and cardiopulmonary resuscitation with rewarming for a pulseless patient. S Afr Med J 2017;107(7):562-565. DOI:10.7196/SAMJ.2017.v107i7.12609

Scenario

An 18-year-old matriculant goes to the beach with friends to celebrate his school results. The ensuing boisterous party includes consumption of alcohol. As dusk falls, he goes for a swim with his girlfriend. She is soon seen waving frantically to their friends back on the beach. He has disappeared below the water surface. Their friends swim out, and after 10 minutes they manage to find him, and bring him to shore. They immediately start cardiopulmonary resuscitation (CPR), while calling for help.

Background

Despite being essential to life, water, which comprises >60% of our body mass and covers >75% of the surface our planet, continues to be an occupational and recreational threat to humans. Drowning among young adults in South Africa (SA) is unfortunately especially common. Poor swimming ability due to historical lack of access to facilities, concomitant alcohol use and easy access to rivers, lakes and the ocean are all contributing factors. This is compounded by relatively limited resources to respond to drowning incidents across

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wide, unpatrolled areas, resulting in a growing burden of disease affecting the younger population groups in SA. Recognition of a drowning event is also a problem, as not every drowning victim will indicate their need for assistance (Fig. 1). This review examines the evidence and recommendations on drowning from an African perspective, and brings the health fraternity one step closer to developing guidelines for our country.

Definition

Drowning is defined as the process of experiencing respiratory impairment from either submersion or immersion in liquid.[1] Drowning outcomes are classified as either drowning with mortality, drowning with morbidity, or drowning without morbidity.[1] Other older terms (such as wet, dry or near drowning) have been deemed unhelpful, and have been abandoned.

Epidemiology

Drowning epidemiology varies dramatically worldwide, but is notably more severe in low- to middle-income countries. US data report ~4 000 drowning deaths, 8 000 hospitalisations and 31 000 emergency department (ED) visits per year for children ˂19 years old.[2] Regrettably, there are no consistent published data for SA, but preliminary information from Lifesaving South Africa (LSA) reveals similar trends in age demographics, although true numbers are largely unknown.[3] Extrapolation from forensic pathology data in the Western Cape provides an estimation of 4/100 000 fatal drownings per year, which is similar to the World Health Organization’s estimations for low-income countries in Africa. Despite only an estimated 1 in 4 cases being reported, Africa has the highest rate of drowning in the world.[4]

Recent guidelines development

Recently updated guidelines for the prevention, prehospital and ED management of drowning have been published by the Wilderness

Medical Society (WMS).[5] However, application of international guidelines within a resource-limited setting must be carefully weighed. In SA, the WMS guidelines are undergoing review by the Wilderness and Expedition Medicine Society of Southern Africa to ensure relevance in the SA context. Nonetheless, they offer evidencebased practice standards, of which the key features and other notable research in the field are being integrated with the Western Cape Drowning Prevention Strategy under development by LSA, the National Sea Rescue Institute (NSRI) of SA, Western Cape Provincial Disaster Management, and the SA Medical Research Council. The ultimate objective is to extend this to developing a national strategy.

Drowning prevention

Drowning is associated with generally poor outcomes, and therefore the initial focus should always be on a pervasive and reiterated prevention strategy. Anyone involved in recreational or professional water-related activities should have baseline medical screening to rule out medical diseases that predispose them for having sudden loss of competence in water. In particular, seizure disorders and prolonged QT syndrome must be sought in children considered at risk.[6,7] A concerted effort must be made to educate children and teenagers on survival swimming (flotation), which should be integrated into life skills programmes at school.[8] Personal flotation devices should be encouraged, irrespective of swimming ability, especially in young children. Adult supervision – particularly in the home environment – is paramount to prevent drowning.[9] Swimming pool covers and barriers to prevent access to pools by small children are essential, but unfortunately remain unregulated in SA. In poorer rural communities where drowning is common in freshwater environments (dams, rivers, ponds, buckets, baths, ditches, sewage latrines or wells), prevention is particularly challenging. Alcohol use before and during swimming must be discouraged.[7] Swimming in areas where there are lifeguards on patrol must also be encouraged or enforced.

Prehospital management

Fig. 1. Contrary to common belief, drowning victims are frequently unable to signal for help, and will often go unnoticed.

The rescue of drowning victims requires specific skills, physical abilities and certified training. Rescues attempted by people who do not fulfil these criteria place the potential rescuers at risk.[5] Individuals without appropriate training should try to reach out to victims, while ensuring that they have secured themselves to a fixed point. If this is unsuccessful, throwing a buoyant device to the victim is an alternative. Depending on the scenario, this may even be the first response while help is sought. If available, a watercraft may be used to reach the victim. None of these efforts should place potential rescuers at risk. Trained rescuers perform at their level of experience, skill and physical abilities, using the equipment they have available. In-water resuscitation is difficult, and should only be attempted when the victim cannot be removed from the water quickly and safely, and only by trained rescuers. There is little evidence to suggest that anything more than ventilation is beneficial for a victim of drowning who is still in the water.[5] Once out of the water, and as soon as possible after addressing immediate threats to life, the victim should be actively and passively warmed, depending on available means. Once it is established that the patient has a pulse, the immediate priorities for resuscitation are airway management, oxygenation and ventilation.[10] For a pulseless person, CPR should commence with chest compressions, with attention to airway patency, ventilations and supplemental oxygen provi-

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sion. The Heimlich manoeuvre is not indicated where water with particulate matter remains the cause of airway obstruction.[11] CPR should follow standard basic life-support principles.[12] Defibrillation may not be effective in severely hypothermic patients, where submersion times were prolonged. The focus here would be effective chest compressions with rewarming.[13,14] The incidence of associated cervical spine injuries in drowning incidents is ˂5%, and is usually associated with diving from a height.[5] Spinal protection is therefore not a concern in drowning unless there is a significant mechanism for cervical spine injury, significant distracting injuries, a focal neurological deficit, anatomical disruption, abnormalities in the cervical spine causing concern or an altered mental status.[15] Unless there is an immediate threat to life or active CPR, there should not be delays in transferring the drowning patient to hospital for assessment and further management. Vascular access is not usually indicated, and undue time should not be spent in the field to gain access.

Emergency department management

The initial priorities for a drowning victim are the same, whether in the prehospital or ED setting. If the patient remains pulseless, the focus is on effective CPR with rewarming, following advanced cardiovascular life-support guidelines.[12] If the patient has a pulse, rewarming and monitoring should occur while attention is paid to airway patency, oxygenation to a targeted peripheral arterial saturation of at least 95%, and adequate ventilation.[16] If mechanical ventilation is used, as indicated, a lung protective strategy should be used with positive end-expiratory pressure (PEEP) and FiO2 to maintain adequate PaO2. Non-invasive ventilation can be considered if there are no contraindications in hypoxic patients with mild to moderate respiratory symptoms. The literature regarding therapeutic hypothermia management for drowning victims is unclear.[17] There may be a role for patients with return of spontaneous circulation after cardiac arrest following drowning.

Unless otherwise indicated, an initial chest radiograph has no value, as it does not correlate with outcomes or other investigations. An initial arterial blood gas measurement may be useful in determining the titration of oxygenation and the need for ventilation.[18] Despite early animal evidence demonstrating pathophysiological differences in salt- and freshwater drowning, this has not been clearly distinguished in humans.[19] Electrolyte abnormalities and changes in osmolarity only occur when >11 - 22 mL/kg of water are aspirated, while studies show that in human drowning ~3 - 4 mL/kg are aspirated.[18] Therefore, the role of routine electrolyte testing is questionable. Alternative diagnoses should be considered if the patient continues to have an altered mental status despite optimal medical therapy. Comorbid illness or injury may have been the precipitating factor for submersion or immersion. Early empiric antibiotic use in ED management is not indicated.[20] It is difficult to differentiate between the stress response of drowning and true infectious aetiology based on early imaging and laboratory testing, and even bedside diagnostics may be insensitive. Antibiotics may be considered with persistently high fever and increased sputum production. Procalcitonin testing may be beneficial to assist in the clinical decision to commence antibiotic therapy. Routine steroid use is similarly not indicated.[20]

Disposition planning

Drowning victims seen in the ED can be observed for 4 - 6 hours and discharged if they present with a mild or absent cough, no abnormal lung sounds or altered mental status, and improve or do not deteriorate during the observation period.[5] Criteria for admission include severe cough, abnormal lung sounds, frothy sputum or foamy material in the airway, hypotension (systolic blood pressure <90 mmHg or mean arterial pressure <60 mmHg) and altered mental status.[5] Several prognostic tools have been suggested to assist with predicting outcomes from drowning. Submersion time has an exponentially negative relationship with survival. Hypoxia remains the main predictor of outcome.[21] If the patient survives to the ED, mortality

Table 1. Classification of drowning patients based on clinical findings on initial presentation and associated mortality Grade

Respiratory findings

Cardiovascular findings

Mortality, %

Normal auscultation and no cough

Radial pulses present

Normal auscultation with mild cough

Radial pulses present

Rales, small amount of foam in mouth

Radial pulses present

0.6

Acute pulmonary oedema

Radial pulses present

5.2

Acute pulmonary oedema

Hypotension

Respiratory arrest

Hypotension

Cardiopulmonary arrest

Pulselessness

Adapted from Schmidt et al.[5]

Table 2. Prediction of mortality in paediatric drowning: the Orlowski score Prognostic factor

Orlowski score

Age <3 years

1 point awarded for each unfavourable prognostic factor Score of ≤2 = 90% chance of recovery Score of ≥3 = 5% chance of recovery

Estimated maximum submersion time >5 minutes No attempts at resuscitation for >10 minutes after rescue Comatose on arrival in emergency department Arterial blood gas pH ≤7.10 Adapted from Anderson et al.[22]

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can still be ≥93%, depending on the initial presentation.[5] Table 1 describes the initial clinical findings and the associated mortality rates. Hypotension alone immediately predicts a mortality of ≥19%. The Orlowski score (Table 2) is used in paediatric drowning scenarios to determine prognosis.[22] When patients present to the ED in cardiac arrest with active resuscitation efforts, a decision must be made on whether to continue with resuscitation. This is often difficult and emotionally charged for ED staff. Poor prognostic indicators from drowning studies are submersion times >30 minutes, with water temperatures >6°C; submersion times >90 minutes, with water temperatures ˂6°C; and at least 25 minutes of continuous high-quality CPR without return of spontaneous circulation.[5,23] In well-resourced settings, bridging to extracorporeal membrane oxygenation may be appropriate, particularly in drowning associated with significant hypothermia.

Scenario resolution

The drowned celebrating matriculant received immediate and highquality bystander CPR from his school friends, who had learnt first aid during their life skills classes. A rapid prehospital response provided advanced cardiovascular life support and swift air transportation to a nearby hospital capable of dealing with drowning victims, where he was rapidly warmed in the ED and admitted to the intensive care unit for 2 weeks. With ideal management, he recovered steadily, and could commence university studies after the holidays, with an intact neurological state.

Conclusion

Drowning prevention and management is a complex interplay between personal and family responsibility, first-responder awareness, prehospital provider training, effective evidence-based ED management and critical care support with appropriate prognostication. It also involves social and government advocacy for preventive interventions that begin at home and are integrated into school programmes. Guidance is required from expert bodies such as LSA and the NSRI, and the collaboration of a multidisciplinary framework of stakeholders to ensure that this problem is addressed nationally and perennially.

Learning points

Drowning is defined as the process of experiencing respiratory impairment from either submersion or immersion in liquid.

Priorities for both prehospital and ED management of the drowning victim include ensuring airway patency, adequate ventilation, supplemental oxygenation and rewarming for a pulsatile patient, and CPR with rewarming for a pulseless patient. The initial priorities for a drowning victim are the same, whether it is in the prehospital or ED setting.

1. Van Beeck EF, Branche CM, Szpilman D, Modell JH, Bierens JJLM. A new definition of drowning: Towards documentation and prevention of a global public health problem. Bull World Health Organ 2005;83(11):853-856. https://doi.org//S0042-96862005001100015 2. Hwang V, Shofer FS, Durbin DR, Baren JM. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med 2003;157(1):50-53. https://doi. org/10.1001/archpedi.157.1.50 3. Donson H, van Niekerk A. Unintentional drowning in urban South Africa: A retrospective investigation, 2001 - 2005. Int J Inj Contr Saf Promot 2013;20(3):218-226. https://doi.org/10.1080/1 7457300.2012.686041 4. World Health Organization. Facts about injuries: Drowning. In: Injuries and Violence Prevention. Geneva: WHO, 2014. 5. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med 2016;27(2):236-251. https://doi.org/10.1016/j.wem.2015.12.019 6. Bell GS, Gaitatzis A, Bell CL, Johnson AL, Sander JW. Drowning in people with epilepsy: How great is the risk? Neurology 2008;71(8):578-582. https://doi.org/10.1212/01.wnl.0000323813.36193.4d 7. Papadodima SA, Athanaselis SA, Skliros E, Spiliopoulou CA. Forensic investigation of submersion deaths. Int J Clin Pract 2010;64(1):75-83. https://doi.org/10.1111/j.1742-1241.2008.01890.x 8. Weiss J, Gardner HG, Baum CR, et al. Policy statement – prevention of drowning. Pediatrics 2010;126(1):178-185. https://doi.org/10.1542/peds.2010-1264 9. Franklin RC, Scarr JP, Pearn JH. Reducing drowning deaths: The continued challenge of immersion fatalities in Australia. Med J Aust 2010;192(3):123-126. 10. Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med 2012;366(22):21022110. https://doi.org/10.1056/NEJMra1013317 11. Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology 2009;110(6):1390-1401. https://doi. org/10.1097/ALN.0b013e3181a4c3b8 12. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81(10):1400-1433. https://doi.org/10.1016/j.resuscitation.2010.08.015 13. Harries M. Near drowning. BMJ 2003;327(7427):1336-1338. https://doi.org/10.1136/bmj.327.7427.1336 14. Salomez F, Vincent JL. Drowning: A review of epidemiology, pathophysiology, treatment and prevention. Resuscitation 2004;63(3):261-268. https://doi.org/10.1016/j.resuscitation.2004.06.007 15. Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J Trauma 2001;51(4):658-662. https://doi.org/10.1097/00005373-200110000-00006 16. Wang TL. Management of victims with submersion injury. Ann Disaster Med 2004;2(Suppl 2):S89-S96. 17. Choi SP, Youn CS, Park KN, et al. Therapeutic hypothermia in adult cardiac arrest because of drowning. Acta Anaesthesiol Scand 2012;56(1):116-123. https://doi.org/10.1111/j.1399-6576.2011.02562.x 18. Topjian AA, Berg RA, Biernes JJLM, et al. Brain resuscitation in the drowning victim. Neurocrit Care 2012;17(3):441-467. https://doi.org/10.1007/s12028-012-9747-4 19. Cushing TA, Hawkins SC, Sempsrott J, Schoene RB. Submersion injuries and drowning. In: Auerbach PS. Wilderness Medicine. Philadelphia: Elsevier, 2012: 1494-1513. 20. Gregorakos L, Markou N, Psalida V, et al. Near-drowning: Clinical course of lung injury in adults. Lung 2009;187(2):93-97. https://doi.org/10.1007/s00408-008-9132-4 21. Ballesteros MA, Gutierrez-Cuadra M, Munoz P, Minambres E. Prognostic factors and outcome after drowning in an adult population. Acta Anaesthesiol Scand 2009;53(7):935-940. https://doi. org/10.1111/j.1399-6576.2009.02020.x 22. Anderson KC, Roy TM, Danzl DF. Submersion incidents: A review of 39 cases and development of the submersion outcome score. J Wilderness Med 1991;2(1):27-36. https://doi.org/10.1580/09539859-2.1.27 23. Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion. Resuscitation 2011;82(7):819-824. https:// doi.org/10.1016/j.resuscitation.2011.02.021

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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Wilderness cold-exposure injuries: An African perspective R Hofmeyr, DipPEC, DA, MMed (Anaes), FCA, FAWM Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town; and WildMedix, Cape Town, South Africa Corresponding author: R Hofmeyr (ross.hofmeyr@uct.ac.za)

Cold injuries may be systemic (hypothermia) or local (frostbite or non-freezing cold injury). Hypothermia (core temperature of <35°C) is very common in South Africa, particularly in trauma patients, and conditions suitable for the development of local cold injuries frequently occur. Despite this, cold injuries are underdiagnosed, and many practitioners lack insight into the modern management of frostbite. Risk factors include low ambient temperatures, increased duration of exposure, trauma, immobility, intoxication or mental illness, lack of protective clothing or equipment, immersion, level of fitness, extremes of age, and ethnicity. Core temperature measurement should be obtained using an oesophageal probe in intubated patients, or a rectal thermometer in those who are conscious. Field management involves prevention of further heat loss by insulation and vapour barriers, and moving the patient to shelter. Rewarming strategies depend on the severity of hypothermia, and include core rewarming with heat packs, warm blankets and warm fluids (orally or intravenously). Unconscious victims of severe hypothermia require careful handling, advanced airway management and invasive rewarming, which may include extracorporeal means. Local cold injuries should be protected and rewarmed in a warm-water bath as soon as they are no longer at a risk of refreezing. Warming should be completed before grading and prognostication. Surgery should be deferred in almost all cases. Intra-arterial thrombolysis and prostacyclin-analogue infusions are novel therapies which may prevent tissue loss. S Afr Med J 2017;107(7):566-570. DOI:10.7196/SAMJ.2017.v107i7.12610

Scenario

As a much-needed break from clinical duties, you have taken your family on a winter week away to a mountain cabin in the Drakensberg. From your chair next to the fire you are watching the snow fall, but are interrupted by a loud knock. A member of another group has not returned from his solo morning walk to the nearby waterfall, and his friends have found him on the trail with a badly sprained ankle from a slip on icy rocks. They are looking for help to carry him back to the cabin, so you readily volunteer. On arrival you find that he is unable to stand unaided, feels very cold and is barely coherent. He complains that he is unable to feel either of his feet. You realise that he is in quite serious danger; mountain rescuers are at least an hour away, and no helicopter can fly through the freshly falling snow. Quickly, you begin to formulate a plan.

ring each season, and local occupational causes (such as individuals working with coolants and refrigeration processes). Furthermore, inadequate attention has been given to the entity of non-freezing cold injury (NFCI), which is possibly underrecognised and underdiagnosed in specific populations such as manual and construction workers, and commercial fishermen in frigid conditions. Because of the relative scarcity of these cases, SA clinicians are typically not well versed in their management. Specialists in fields such as trauma, and vascular and plastic surgery may not be familiar with the differences in injury progression and management from other causes of tissue ischaemia and necrosis, such as chronic peripheral vascular disease. This brief review aims to provide the African practitioner with an overview and understanding of the issues surrounding diagnosis and management of systemic and local cold injuries in our context.

Background

Systemic cold injury: Hypothermia

South Africa (SA) immediately conjures images of sun, heat, dry deserts and lush jungle, but any Karoo farmer or resident of the highveld will attest to the severity of chill winter nights. Our mountainous regions and the high interior of the country enjoy frequent snowfall, and winter temperatures routinely reach subzero at night. Indeed, the coldest recorded temperature in SA (measured by the SA Weather Service at Buffelsfontein near Molteno in the Eastern Cape Province in June 1996) was –18.6°C.[1] However, freezing temperatures are not required to place both healthy individuals and ill or injured patients at risk of cold injury. Systemic cold injury – hypothermia – is dichotomously extremely common and highly underdiagnosed in traumatic injury victims, and is not uncommon even in hospitalised patients presenting for surgery or intensive care.[2-7] Local cold injuries such as frostbite are rarely considered in SA, but as described above, suitable conditions definitely exist, and accidental cases within our borders have been described.[8] Further cases are contributed through Cape Town’s role as one of the international gateways to Antarctica, with several medical repatriations occur-

Definition

Normal core body temperature is subject to tight homeostatic control of less than half a degree around a set point of ~37°C. This varies between individuals, and shows both gender and diurnal variation. Hypothermia is traditionally defined as a core temperature of <35°C.[9] (While this definition is widely accepted in the literature, it is worth noting that the peri-operative literature considers a temperature of <36°C to be peri-operative hypothermia, as this has been associated with increased complications.) Any individual presenting with a temperature of <35°C should therefore be considered hypothermic and warmed to a target of 36 - 37°C.

Risk factors

Hypothermia risk is closely related to ambient temperature and duration of exposure, but is also influenced by the level of fitness and physical activity, body habits, age, experience, protective clothing and equipment, presence of immersion in water or soaking of clothes of the victim. Ethnicity is relevant in Africa, and does play a role: in

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groups with equal exposure, those of African ethnic heritage have been shown to be at greater risk than Caucasians.[10-12] There is also a strong association between mental illness, alcohol and drug intoxication and hypothermia risk. However, cold injuries are completely preventable through education, appropriate clothing and equipment, and good decision-making in the wilderness (Fig. 1). Interventions to reduce the burden of disease should focus on these strategies.

pulmonary artery catheter. Outside of the research setting, this is practically impossible in the field, and is rare even in clinical practice in the emergency department. Using a mid-oesophageal thermistor is considered of equal accuracy, with response times to changes in temperature nearly as swift as pulmonary artery measurement. Although

Wilderness hypothermia guidelines

Multiple guidelines on the management of hypothermia exist.[13-15] In the wilderness setting, those published by the Wilderness Medical Society and International Commission on Alpine Rescue are particularly useful, with relevant modification for the SA context. A brief overview is provided below. Accidental hypothermia in the wilderness setting has been classified by numerous means, including symptoms and clinical signs, and measured core temperature (Table 1). Field diagnosis and progression of hypothermia can be assisted by the aide mémoire of the ‘umbles’: the patient grumbles, fumbles, stumbles, mumbles and finally crumbles.[16] This reflects the change in personality as individuals begin to feel cold, the progressive loss of first fine and then gross motor co-ordination, the late descent into incoherence, and final collapse. Additional signs are the onset and later loss of shivering, pallor and inappropriate behaviour. Core temperature measurement is critical in managing hypothermia. However, this presents several problems and misconceptions. The gold standard of core temperature determination is direct measurement in the pulmonary artery using a thermistor-tipped

Fig. 1. A well-equipped individual in harsh environmental conditions. Care has been taken to prevent skin exposure to high winds through the use of goggles, a face mask and gloves. Insulation is worn under a windproof outer layer to reduce conductive, convective and evaporative heat loss.

Table 1. Comparison of Wilderness Medical Society staging and Swiss hypothermia classification with clinical signs and management recommendations Core temperature

Clinical signs

Wilderness Medical Society guidelines[9]

Swiss hypothermia grading[13]

>36°C

Normal

>35°C

Feeling cold

Cold stressed, not hypothermic

35°C

Shivering commences

34°C

Loss of fine motor co-ordination

Mild HT (32 - 35°C)

HT I: clear consciousness with shivering

33°C

Behaviour changes, dysarthria

Prevent further loss; measure core temperature; encourage passive warming by caloric replacement; warm actively if possible

32°C

Lethargy

31°C 30°C

Ataxia and impaired consciousness

Moderate HT (28 - 32°C)

HT II: impaired consciousness with shivering

29°C

Shivering stops

28°C

Decreased fibrillation threshold

As above, plus active warming in all cases: warm fluids, heat packs, forced air warmers; intravenous or intraosseous access, protection from trauma, afterdrop and shocks

27°C

Loss of consciousness

Severe HT (<28°C) Profound HT Loss of reflexes and pain (<24°C or <20°C) response

HT III: unconscious

<24°C

Hypotension and bradycardia

HT IV: apparent death

<13°C

Undetectable vital signs; asystole likely below 18°C

HT V: irreversible hypothermic death

As above, plus protect airway (SGA or careful intubation); supplemental O2; ventilation; oesophageal temperature probe; CPR if no signs of life; warm invasively and aggressively; terminate if serum potassium >12 mmol/L or injuries incompatible with life

26°C 25°C 24°C

HT = hypothermia; CPR = cardiopulmonary resusitation; SGA = supraglottic airway.

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Management recommendations

Reduce heat loss by shelter or clothing; increase heat production with exercise or food

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feasible in the field, it typically requires an unconscious or sedated patient who has an advanced airway device in place. However, many modern monitoring devices (including those used in prehospital medicine, the emergency department and the operating theatre) can be used for this propose. Rectal temperature measurement using either a thermistor or thermometer is accurate and accessible, but slower to respond to rapid temperature changes. A low-reading thermometer that is inserted to 15 cm beyond the anal sphincter is ideal. Barriers to use include social acceptability, and the need to remove clothing if in the field, thereby exposing the patient to further cold insult. Oral measurement is also suboptimal: it is greatly affected by respiration and fluid intake, and is therefore of little use if warming is being undertaken by administration of hot fluids. However, oral temperature measurement can be useful to rule out hypothermia if >35°C before taking warm fluids. Axillary and skin temperatures are unreliable in patients with hypothermia. True tympanic membrane measurement reflects central compartment blood temperature by direct perfusion via the carotid artery, but requires an epitympanic contact thermistor, which is rarely available in the field and influenced by ambient temperature if incorrectly placed and not insulated. Infrared tympanic thermometers, despite their convenience, have consistently been shown to be unreliable.[17]

Field management

Once the safety of rescuers has been confirmed, the first priority in field management of hypothermia is prevention of further heat loss through the use of insulation and vapour barriers. Any dry item that traps air (clothing, blankets, sleeping bags or even bubble wrap) can be used for insulation. A vapour barrier is a layer impermeable to water vapour (and wind), which dramatically reduces convective and evaporative heat loss. Although specific products such as survival bags exist for this purpose, in low-resource settings even simple plastic refuse bags are effective. In mild hypothermia (conscious patients who can walk), preventing further heat loss, providing warm calorie-rich drinks and allowing the patient to increase endogenous heat production by shivering or continuing to exercise, can be sufficient to ensure rewarming. If the patient is not able to drink or ambulate, moderate to severe hypothermia must be presumed. Rapid peripheral warming or exercise may precipitate ‘afterdrop’, where redistribution of blood from the central circulation to the periphery results in rapid drop of core temperature. Cooling lengthens the refractive period of cardiomyocytes, which can result in ventricular fibrillation (VF) and complete circulatory collapse. Therefore, exercise in these patients should be avoided if possible. They should be carried to shelter, and have active core rewarming using items such as heat packs or warm-water bottles, warm carbohydrate-containing fluids, and warmed blankets. Deliberate warming of cold extremities should only occur once core temperature has normalised. Unconscious victims of severe hypothermia may appear dead. However, in the absence of injuries incompatible with life, efforts at warming and resuscitation should be made, if possible. This includes advanced airway management, vascular access (intraosseous access may be easiest in very cold patients), warm intravenous fluids, core rewarming and cardiopulmonary resuscitation (CPR).

Hospital management

Core rewarming efforts should be continued when patients present to hospital. The patient should be admitted to a monitored bed, with electrocardiograph, saturation, blood pressure and temperature monitoring as a minimum. Forced-air warming devices are effective, but care must be taken that the patient is dry before their application.

Any wet or restrictive clothing must be removed. Intravenous access should be obtained, which may require intraosseous catheterisation with infusion fluids at 40 - 42°C. Unconscious patients should have an advanced airway (endotracheal tube or supraglottic airway) and mechanical ventilation. In the absence of palpable pulses, production of end-tidal carbon dioxide or the use of point-of-care ultrasound to assess cardiac activity and output are very valuable. Patients with an organised cardiac rhythm but no discernible pulse should have ongoing warming and resuscitation with fluid. If VF is present, a single attempt at defibrillation can be made. If unsuccessful, the patient should be warmed to at least 30°C before further attempts are made. Hypothermic patients may have a decreased response to vasoactive agents. Invasive warming through bladder, and peritoneal or pleural lavage can be used in severe cases. Extracorporeal rewarming and support of perfusion are gaining international acceptance in centres that have this capability, and should strongly be considered where available, as discussed in ‘Emerging therapies’ below.

Local cold injuries

Local cold injuries can be subdivided into frostnip, frostbite and NFCI. Frostnip is the reversible freezing of only the most superficial layer of the epidermis without any underlying tissue injury, and resolving within 30 minutes. As it is rare at temperatures >–10°C and only common at <–25 °C, it is exceptionally rare in the African context. Frostbite involves the freezing of skin and other tissues resulting in damage to the affected area, which may heal or result in permanent tissue loss. Typically, this requires ambient temperatures below that at which tissue freezes (–0.55°C), although it can occur at higher temperatures in the presence of significant convective cooling (wind chill). The severity of injury is dependent on duration of exposure, ambient temperature, evaporative cooling or immersion, type of clothing and/or exposure protection, underlying conditions that affect perfusion (such as diabetes, smoking, Raynaud’s phenomenon and other peripheral vascular diseases) and the presence of alcohol/ drug intoxication or mental illness. Of these factors, duration of exposure is the most critical. The precise mechanism of injury is not fully understood, but involves direct injury from formation of intracellular and extracellular ice crystals, subsequent intracellular dehydration due to increased oncotic pressure, and reperfusion injury during tissue warming. Endothelial damage leads to tissue oedema and formation of microthrombi, which occlude capillaries and worsen tissue ischaemia. Repeated freeze-thaw cycles lead to the most severe injuries. In early frostbite, the area involved feels cold and may be painful, progressing to paraesthesia and/or numbness. The skin is pale or mottled. Later, the area becomes white and waxy to touch, and may be clearly demarcated. The tissue is insensate and feels woody (Fig. 2). With rewarming, erythema, bruising and blisters may form. Clear fluid-filled blisters imply full-thickness involvement of the skin (often described as mild or second-degree frostbite), whereas haemorrhagic blisters demonstrate the subcutaneous tissue damage of severe (third-degree) frostbite, which more frequently leads to tissue damage (Fig. 3). Absence of blisters in the presence of dark mottled tissue after rewarming indicates profound frostbite, which often involves muscle, tendon or bone, and will likely result in significant tissue loss though mummification and necrosis (Table 2). NFCI usually presents with unresolving numbness, often accompanied by pain or paraesthesia. Upon rewarming, the site (usually a foot) becomes hyperaemic and oedematous. There is not usually blistering or tissue loss; if present, the injury should be treated as frostbite. Unrelenting pain is common and should be managed

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Fig. 2. Acute presentation of frostbite in a scientist at the SA Antarctic research station, superimposed on minor tissue loss from an earlier episode. Note the waxy white appearance of several fingertips, most easily seen on the third finger of the left hand. (Photo: author’s collection.)

Fig. 3. Mixed frostbite lesions after thawing. Note hyperaemia (1st degree) of thenar area and presence of clear and haemorrhagic blisters (2nd and 3rd degree) on fingertips. Distal phalynx cyanosis (grade 2) hidden by protective dressings. (Photo: author’s collection.)

aggressively. As it is neurogenic in origin, agents used for chronic pain management should be considered. In our setting, amitriptyline (25 mg initially) is an effective first-line agent. Frostbite carries the prospect of significant morbidity, but is not an acute threat to life. However, in the wilderness it is almost always accompanied by a degree of hypothermia, and often with

other traumatic injuries. The priority, therefore, is the immediate management of life-threatening conditions, including core rewarming if hypothermia is present. Indeed, aggressive peripheral warming in the presence of hypothermia may result in dangerous afterdrop in core temperature. Because duration of exposure is the principal factor determining severity of frostbite, rapid rewarming of the frozen part is important. However, rewarming should not be attempted if it will impede removing the patient to a sheltered environment, or if refreezing may occur. For instance, a patient with frostbite of the feet may be able to walk to safety, but once rewarming has commenced would be unable to move unaided. Rewarming is ideally performed in a water bath at 37 - 42°C. In the field, the armpit or groin of a warm rescuer can be used. Care should be taken with the use of hot-water bottles, stoves or other heat sources, as the patient may be unable to feel the limb, or already be in sufficient pain that they cannot distinguish when burning of the tissue occurs. Rewarming is typically painful and analgesia should always be given. Aspirin (500 mg taken orally) may benefit rheology, and ibuprofen (800 mg initially followed by 400 mg 8-hourly) is useful for both analgesia and antiprostaglandin effects. Paracetamol, opiates and other modalities such as ketamine and methoxyflurane can be considered. Local or regional blocks with local anaesthetic provide good relief, and the resultant sympathectomy may be useful in improving perfusion, but this should be restricted to skilled hands and not used in NFCI, where it worsens the risk of chronic pain. The affected part should be protected well with dry dressings. Blisters, if present, should not be deroofed. If very tense, some experts advise aspirating haemorrhagic blisters under strict aseptic conditions. If available in the field, simple prophylactic antibiotics can be given. Patients with any evidence of tissue damage/loss (grade 2 frostbite or higher) should always be evacuated to a suitable healthcare facility for assessment, as field diagnosis is poorly predictive of actual degree of tissue involvement. On admission to hospital, patients with local cold injuries should be rapidly assessed to rule out hypothermia or other life-threatening insults. A targeted history, including duration of exposure, duration of freezing and time since rewarming, should be obtained. Any rings or jewellery must be removed. Prognostication or grading before thawing is not accurate and the affected areas should be rewarmed as soon as possible. The ideal method is by using a whirlpool bath at 37 - 42°C. Where this is not available, a common foot spa bath or large basin with continuous stirring can be used. Care must be taken not to exceed this temperature. As mentioned previously, rewarming is usually very

Table 2. Grading/classification of frostbite injuries Traditional classification[18]

Modern grading[19]

Tissue loss

1st degree Partial thick skin freezing; erythematous or hyperaemic with minor oedema once thawed

Grade 1 No cyanosis visible on extremity after thawing

None

2nd degree Full-thickness skin freezing; erythematous with oedema; clear blisters once thawed

Grade 2 Cyanosis after thawing is restricted to distal phalanx

Rare/unlikely; limited to nails and soft tissue

3rd degree Skin and subcutaneous tissue freezing; cyanotic blue/black tissue with haemorrhagic blisters once thawed; may have necrosis

Grade 3 Cyanosis after thawing extends to intermediate and proximal phalanx

Mild to moderate; often loss of distal tip of extremity

4th degree Grade 4 Skin, subcutaneous tissue, muscle, tendon Cyanosis extends to carpal/tarsal bones and bone freezing; little oedema but deeply after thawing red/purple tissue becoming black and mummified

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Amputation commonly required, with functional sequelae

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painful and adequate analgesia must be given. Adequate rewarming time varies from 30 to 60 minutes, but can be judged clinically by palpation of pliable tissue and appearance of a red or purple colour. Once thawed, the degree and grading of the injury can be established. Documentation using photographs is recommended, following which loose protective dressings can be applied. Some centres recommend the use of topical aloe vera gel for its antiprostaglandin effect, and simple antibiotic and tetanus prophylaxis. Early surgical intervention is not advocated unless there is unambiguous evidence of compartment syndrome after thawing. This occurs rarely. Surgeons used to seeing gangrene from peripheral vascular disease, but who have little or infrequent exposure to frostbite cases, may not anticipate the degree to which frostbite injuries can be salvaged. Certainly, surgery should not be undertaken in the absence of obvious sepsis without first performing imaging of the affected area. In this respect, either digital subtraction angiography or technetium-99 bone scanning have been shown to provide the best prognostic information.[20,21] More recently, magnetic resonance angiography, which may be more widely available in SA, has been used as an alternative. Early angiography, however, does offer the option of performing intra-arterial thrombolysis (discussed below). Deep frostbite injuries will normally demarcate clearly with dry necrosis of the devitalised tissue, allowing amputation at 6 - 12 weeks post injury. There is a strong association between frostbite injuries requiring amputation and chronic regional pain. Analgesia before and after amputation should therefore be optimal and early referral to a pain specialist is warranted if the patient's pain is not well controlled.

Emerging therapies for cold injuries

The increasing use of extracorporeal life support and/or extracorporeal membrane oxygenation (ECMO) worldwide has led to recognition of its value in providing rapid central rewarming to patients with severe hypothermia. Although ECMO is still rare in SA, any hospital that provides cardiopulmonary bypass services for cardiothoracic surgery has the capability to rewarm patients in this fashion. Suitable cases – particularly those in which profound cooling occurred before apparent cardiorespiratory arrest – should be considered for early involvement of teams (typically cardiac surgeons and perfusionists) if this is to be attempted. In some settings, recovery to normal neurological function has been achieved after profound hypothermia. Indeed, full recovery has been recorded after accidental hypothermia with a core temperature of 13.7°C using this approach.[22] Many novel approaches have been attempted for management of frostbite, including hyperbaric oxygen therapy, alpha-adrenergic and calcium channel blockers, phosphodiesterase inhibitors, systemic heparinisation and topical therapies. Of these, the most promising interventions that have entered routine practice are the use of intra-arterial thrombolysis, and intravenous prostacyclin analogue infusions.[23-25] Several studies have shown that initiation of thrombolysis with recombinant tissue plasminogen activator and/or iloprost infusion commenced within 24 hours of rewarming significantly decreases the degree of tissue loss due to frostbite.[26,27] Iloprost carries the advantage of not requiring facilities for angiography, but the intravenous version of the drug is not widely available; this indication is considered off-label. Some work suggests that thrombolysis may not add to therapy where iloprost is available, but it is still used for severe cases and where iloprost cannot be obtained.[26] While this is achievable in an African setting, it should only be attempted in units with experience in endovascular thrombolysis, where adequate monitoring is available and contraindications have been excluded.[24]

Scenario resolution

High in the Drakensberg, you recognise that your impromptu patient may well have frostbite, but the greatest danger comes from his obvious moderate to severe hypothermia. Concerned by his confusion and inability to stand, you have the group carry him to one of the cabins while a member of the party calls for an ambulance. Removing his wet clothing, shoes and rings, you wrap him in blankets warmed at the fire. With assistance he can sip warm, sweet tea. You accompany him to the hospital, where his core temperature is recorded at 33.5°C on arrival, and warming is continued using a forced-air warmer, and his feet are thawed in water baths at 40°C. Seeing evidence of at least grade 3 frostbite of his toes, you are able to discourage the local surgeon from aggressive debridement, rather recommending transfer to a referral centre. You later hear that he underwent angiography and thrombolysis, which prevented significant tissue loss.

1. South African Weather Service. What are the temperature, rainfall and wind extremes in SA? 2017. http://www.weathersa.co.za/learning/climate-questions/39-what-are-the-temperature-rainfall-andwind-extremes-in-sa (accessed 2 April 2017). 2. Baumgartner EA, Belson M, Rubin C, Patel M. Hypothermia and other cold-related morbidity emergency department visits: United States, 1995 - 2004. Wilderness Environ Med 2008;19(4):233237. http://dx.doi.org/10.1580/07-WEME-OR-104.1 3. Lapostolle F, Couvreur J, Koch FX, et al. Hypothermia in trauma victims at first arrival of ambulance personnel: An observational study with assessment of risk factors. Scand J Trauma Resusc Emerg Med 2017;25(1):43. http://dx.doi.org/10.1186/s13049-017-0349-1 4. Lapostolle F, Sebbah JL, Couvreur J, et al. Risk factors for onset of hypothermia in trauma victims: The HypoTraum study. Crit Care 2012;16(4):R142. http://dx.doi.org/10.1186/cc11449 5. Ireland S, Endacott R, Cameron P, Fitzgerald M, Paul E. The incidence and significance of accidental hypothermia in major trauma – a prospective observational study. Resuscitation 2011;82(3):300-306. http://dx.doi.org/10.1016/j.resuscitation.2010.10.016 6. Waibel BH, Schlitzkus LL, Newell MA, Durham CA, Sagraves SG, Rotondo MF. Impact of hypothermia (below 36 degrees C) in the rural trauma patient. J Am Coll Surg 2009;209(5):580-588. http://dx.doi. org/10.1016/j.jamcollsurg.2009.07.021 7. Hardcastle TC, Stander M, Kalafatis N, Hodgson RE, Gopalan D. External patient temperature control in emergency centres, trauma centres, intensive care units and operating theatres: A multi-society literature review. S Afr Med J 2013;103(9):609-611. http://dx.doi.org/10.7196/samj.7327 8. Ahmad Z. Managing frostbite in a South African patient. Int Wound J 2013;10(4):480-481. http:// dx.doi.org/10.1111/j.1742-481X.2012.00946.x 9. Zafren K, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia. Wilderness Environ Med 2014;25(4):425-445. http://dx.doi.org/10.1016/j.wem.2014.09.002 10. DeGroot DW, Castellani JW, Williams JO, Amoroso PJ. Epidemiology of US Army cold weather injuries, 1980 - 1999. Aviat Space Environ Med 2003;74(5):564-570. 11. Burgess JE, Macfarlane F. Retrospective analysis of the ethnic origins of male British army soldiers with peripheral cold weather injury. J R Army Med Corps 2009;155(1):11-15. 12. Maley MJ, Eglin CM, House JR, Tipton MJ. The effect of ethnicity on the vascular responses to cold exposure of the extremities. Eur J Appl Physiol 2014;114(11):2369-2379. http://dx.doi.org/10.1007/ s00421-014-2962-2 13. Durrer B, Brugger H, Syme D, Tipton MJ. The medical on-site treatment of hypothermia: ICAR-MEDCOM recommendation. High Alt Med Biol 2003;4(1):99-103. http://dx.doi.org/10.1089/152702903321489031 14. McIntosh SE, Opacic M, Freer L, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med 2014;25(Suppl 4):S43-S54. http:// dx.doi.org/10.1016/j.wem.2014.09.001 15. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81(10):1400-1433. http://dx.doi.org/10.1016/j.resuscitation.2010.08.015 16. Davis I, Johnson C, Johnson C, Oakley H, Roberts B. Cold climates. In: Imray C, ed. Oxford Handbook of Expedition and Wilderness Medicine. Oxford: Oxford University Press, 2015:607-636. 17. Strapazzon G, Procter E, Paal P, Brugger H. Pre-hospital core temperature measurement in accidental and therapeutic hypothermia. High Alt Med Biol 2014;15(2):104-111. http://dx.doi.org/10.1089/ ham.2014.1008 18. Mills WJ Jr. Summary of treatment of the cold injured patient. Frostbite. Alaska Med 1983;25(2):33-38. 19. Cauchy E, Chetaille E, Marchand V, Marsigny B. Retrospective study of 70 cases of severe frostbite lesions: A proposed new classification scheme. Wilderness Environ Med 2001;12(4):248-255. 20. Cauchy E, Chetaille E, Lefevre M, Kerelou E, Marsigny B. The role of bone scanning in severe frostbite of the extremities: A retrospective study of 88 cases. Eur J Nucl Med 2000;27(5):497-502. 21. Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. J Hand Surg Am 2000;25(5):969-978. 22. Gilbert M, Busund R, Skagseth A, Nilsen PA, Solbø JP. Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest. Lancet 2000;355(9201):375-376. http://dx.doi.org/10.1016/ S0140-6736(00)01021-7 23. Hallam MJ, Cubison T, Dheansa B, Imray C. Managing frostbite. BMJ 2010;341:c5864. http://dx.doi. org/10.1136/bmj.c5864 24. Handford C, Buxton P, Russell K, et al. Frostbite: A practical approach to hospital management. Extrem Physiol Med 2014;3:7. http://dx.doi.org/10.1186/2046-7648-3-7 25. Handford C, Thomas O, Imray CHE. Frostbite. Emerg Med Clin North Am 2017;35(2):281-299. http:// dx.doi.org/10.1016/j.emc.2016.12.006 26. Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. N Engl J Med 2011;364(2):189-190. http://dx.doi.org/10.1056/NEJMc1000538 27. Cauchy E, Davis CB, Pasquier M, et al. A new proposal for management of severe frostbite in the austere environment. Wilderness Environ Med 2016;27(1):92-99. http://dx.doi.org/10.1016/j. wem.2015.11.014

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IN PRACTICE

MEDICINE AND THE LAW

The evolution of research participant protections in South Africa A Dhai, PhD, MB ChB, FCOG, LLM, PG Dip (Int Res Ethics) Steve Biko Centre for Bioethics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: A Dhai (ames.dhai@wits.ac.za)

South Africa (SA) has played a leading role in health research internationally. Ethical guidelines for the protection of research participants have been published by the Medical Research Council (MRC) as early as 1979. Ironically, the guidelines gave substantial prominence to the oppressive laws of the time. In its 4th edition of the guidelines, the MRC placed emphasis on SA needs, and incorporated the principles of the Bill of Rights of the SA Constitution 1996 into its guidelines. The most significant milestone in the history of participant protections in SA was the inclusion of research and experimentation in the Bill of Rights of the Constitution and the statutory legislation of protections in the National Health Act No. 61 of 2003. S Afr Med J 2017;107(4):571-572. DOI:10.7196/SAMJ.2017.v107i4.12438

South Africa (SA) has played a leading role in health research internationally. SA’s history in this context dates back to the 1800s. The legislative basis for scientific research was first promulgated in 1945. However, there was then legislative and regulatory silence on protecting participants enrolled in research, and it was only about 60 years later that the National Health Act[1] (NHA) was promulgated, which prescribed clearly what the legal safeguards would be for participants in health research. Despite this legal hiatus, individual institutions and researchers drew from international norms and standards, and set up protective instruments for ethical oversight in health research. These efforts have been detailed in the previous issue of the series.[2,3] This article describes the SA Medical Research Council’s (SAMRC’s) journey in guidelines development for participant protections, the protections in the Bill of Rights of the SA Constitution[4] and the NHA,[1] and concludes SA’s journey in protecting the human dignity of participants enrolled in research.

The SAMRC research ethics guidelines[5]

In December 1979, the SAMRC published its first set of guidelines, entitled A Guide to Ethical Considerations in Medical Research,[6] to safeguard the rights and welfare of human subjects involved in activities supported by grants or contracts from the council. The guidelines emphasised in the introduction that it was of paramount importance for any ethical code relating to medical research to err in the ‘direction of stringency rather than laxity, and no man should find himself in the position of solely being judge of his own morals in research’. Ironically, substantial emphasis was placed on the oppressive laws of the time and the guidelines (also known as the Code) stated that:[6] ‘The provision of this Code may not be construed in any manner or sense that would abrogate, supersede, or moderate more restrictive applicable law or precedential legal decisions.’ Furthermore, in its statement of principles, it was affirmed that institutions should adopt a statement of principles that would assist in their discharge of responsibilities for the protection of the rights and welfare of subjects. It went on to state that:[6] ‘This official guide of the SAMRC may be used as a guideline for such a statement and care should be exercised to ensure that the

principles outlined in the said statement do not supersede SAMRC policy or any legal rule.’ It was paradoxical that for the safeguarding of rights and dignities of participants, such importance was placed in the law, especially as this was in the context of the apartheid era where people of colour were oppressed and their rights abused. The Code’s approach to minors illustrates quite aptly the MRC’s strict adherence to the law. The stipulations of the then-Children’s Act, No. 33 of 1960, were endorsed by the Code,[6] and parents would be the guardians of minors in research, with the father having the final say; however, where the child was illegitimate, its mother alone was its legal guardian. The document further stated that the position was more complicated where black Africans were concerned. Most ‘Bantu’ women were usually in the position of minors, and fell under the guardianship of their father or the head of the kraal if unmarried, and under the authority of their husband if married. [6] The guardianship of a ‘Bantu’ child was difficult to establish, as SA law and the stateimposed Bantu law were in conflict on that point. A customary union was not recognised as a lawful marriage, according to SA law. This created uncertainty as to whose consent would have to be obtained for a child born in a customary union. It recommended that the consent of the legal guardian recognised by each system be obtained in order to avoid any problems that might have arisen from this uncertainty.[6] Again, it is remarkable that the SAMRC placed such importance on the laws, especially considering there were two sets – SA law and Bantu law. The latter applied to indigenous black South Africans, who clearly were not acknowledged as being on a par with others in the country. They were considered a lesser form of life, with no moral status or human dignity, and therefore did not qualify to benefit from the protections offered by SA law. Eight years after the first edition, the SAMRC launched its Ethical Considerations in Medical Research. Revised Edition: 1987. [7] There are no recorded external influences on the revised guidelines, and the reason given for the revision was that medical science was progressing at a rapid rate, and new ideas and questions that had not seemed to be significant just a decade back had become part of the ordinary problems that researchers had to deal with regularly. Of note is that the focus on complying with the legal framework was

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carried through into the second edition, although the term ‘Bantu’ was replaced with ‘Black’. In addition, KwaZulu law was expanded upon for black women living in Natal, whose status upon acquiring majority at the age of 21 was no longer determined by a guardian. Moreover, the Kwa-Zulu Act on Medical and Surgical Treatment, No. 11 of 1986,[7] allowed for a married woman in certain circumstances to consent independently to treatment. The situation with regard to black children born of a customary union was also clarified. According to indigenous law, the consent had to be given by both the father and the head of the kraal. Where the child was illegitimate, consent had to be given by the mother and her legal guardian. The Code went on to state that these stipulations were valid only where the researcher and subject were both black. Where the researcher was not black, the ordinary principles of SA law were valid and the legal incompetence of black women according to traditional law did not apply.[7] It is highly likely that these discriminatory distinctions between professionals created many tensions and conflicts, and even confusion. With the promise of transition from apartheid to democracy just around the corner, the early 1990s in SA witnessed a flurry of activities towards change in laws and policies that took into consideration the rights and dignity of all South Africans. In the context of research, the Medical Research Act, No. 19 of 1969 was replaced by the MRC Act, No. 58 of 1991,[8] and the guidelines were further amended and replaced by Guidelines on Ethics for Medical Research – Revised Edition, 1993.[9] Of note is that this set of guidelines made no reference to separate laws for black population groups and SA laws for other groups, as had been the case in the previous guidelines. The guidelines and laws referred to in this document applied to all South Africans equally, irrespective of colour. This is presumably because SA was on the brink of liberation and a democratic government. Almost a decade after the SAMRC’s 3rd edition of guidelines were published, the next set of revisions was issued in 2004.[10] This was owing to a number of important factors, including major sociopolitical reform in SA, and great interest globally in the field of ethics in research, especially as a resurgence of transgressions around the world were being exposed. For its 4th edition, the SAMRC placed emphasis on SA needs, and incorporated the principles of the Bill of Rights of the SA Constitution, 1996 into its guidelines.[4] In addition, developing-country concerns were stressed.

Participant protections in SA: Law reform

The most significant milestone in the history of participant protections in SA was the inclusion of research and experimentation in the Bill of Rights of the Constitution,[4] and the statutory legislation of protections in the NHA.[1] Section 12(2)(c) of the Bill of Rights, on freedom and security of the person, affirms everyone’s right to bodily and psychological integrity, including the right ‘not to be subjected to medical and scientific experiments without their informed consent’. Other protections for research in the Bill include the rights to equality (s 9), human dignity (s 10), life (s 11), and privacy (s 14). For the first time in the history of SA, protections for participants in research were made mandatory by statutory law in 2003, and so strong protectionism was mandated by legislation. Health research in terms of section 1 of the NHA includes: ‘any research which contributes to the knowledge of – • the biological, clinical, psychological or social processes in human beings;

• • • • •

improved methods for the provision of health services; human pathology; the causes of disease; the effects of the environment on the human body; the development of new applications of pharmaceuticals, medicines and related substances; and • the development of new applications of health technology.’ This definition is very broad and covers a wide range of research activities, which, in terms of section 73 of the Act, will need to be reviewed by health research ethics committees that are registered with the National Health Research Ethics Council (NHREC). The establishment of the NHREC is provided for in section 72 of the Act. The function of the NHREC includes, among others, that of determining guidelines for the functioning of health RECs.

Conclusion[5]

The Nuremberg Code was the first international document in research ethics. It was established as a response to the disasters and disgrace in medical research generated by the Nazi doctors as highlighted in the previous article in this series.[3] SA started establishing protections for participants of research from the late sixties. In SA, the protectionist approach was not as a response to scandals and tragedies inflicted on vulnerable participants by SA researchers, as it had been internationally, but because of a sense of moral agency, moral responsibility and moral accountability of researchers in this country towards the people they enrolled in research. SA researchers drew from Aristotelian and Hippocratic influences in their professional practice and embarked on the protectionist approach as a safeguard against atrocities and human dignity violations similar to the ones that Beecher3,11 described, especially because sponsors and researchers from well-resourced countries, and in particular the USA, had started finding less wellresourced areas highly attractive for the conduct of clinical research. SA researchers established protections for participants enrolled in research long before the legislative mandate to do so. Acknowledgements. None. Author contributions. Sole author. Funding. None. Conflicts of interest. None. 1. South Africa. The National Health Act No. 61 of 2003. 2. Dhai A. Health research and safeguards: the South African journey. S Afr Med J 2017;107(5):379-380. http://doi.org/10.7196/SAMJ.2017.v107i5.12345 3. Dhai A. Exploitation of the vulnerable in research: Responses to lessons learnt in history. S Afr Med J 2017;107(6):472-474. DOI:10.7196/SAMJ.2017.v107i6.12437 4. South Africa. Constitution of the Republic of South Africa, Bill of Rights, Act No. 108 of 1996: s 36(1). 5. Dhai A. A study of vulnerability in health research. PhD thesis. Johannesburg: University of the Witwatersrand, 2015. 6. De V Lochner J. A Guide to Ethical Considerations in Medical Research. Parrowvallei: South African Medical Research Council, 1979. 7. De V Lochner J. Ethical Considerations in Medical Research. Parrowvallei: South African Medical Research Council, 1989. 8. South Africa. Medical Research Council Act, No. 58 of 1991. 9. South African Medical Research Council. Guidelines on Ethics for Medical Research. 3rd ed. SAMRC: Cape Town, 1993. 10. South African Medical Research Council. Guidelines on Ethics for Medical Research: General Principles, 2002. http://www.mrc.ac.za/ethics/ethicsbook1.pdf (accessed 22 August 2013). 11. Beecher HK. Ethics and clinical research. N Engl J Med 1966;274(24):1354-1360. https://doi. org/10.1056/NEJM196606162742405

Accepted 17 March 2017.

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IN PRACTICE

ISSUES IN MEDICINE

Perceptions of nurses’ roles in end-of-life care and organ donation – imposition or obligation? K Crymble,1 Dip Nursing; J Fabian,1,2 MD; H Etheredge,1 MScMed, PhD; P Gaylard,3 PhD Wits Donald Gordon Medical Centre, Johannesburg, South Africa Division of Nephrology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Data Monitoring and Statistical Analysis (DMSA), Johannesburg, South Africa 1 2

Corresponding author: K Crymble (kim.crymble@mediclinic.co.za)

South Africa has a rich organ-transplant history, and studies suggest that the SA public supports organ donation. In spite of this, persistently low donor numbers are a significant challenge. This may be due to a lack of contextually appropriate awareness and education, or to barriers to referring patients and families in clinical settings. It may also be due to ad hoc regulations that are not uniformly endorsed or implemented. In this article we present the findings of a study in Johannesburg that explored the attitudes and roles of nurses in endof-life care and organ donation. A total of 273 nurses participated. Most were female and <50 years old. The majority expressed positive attitudes towards both end-of-life care and organ donation, but there was ambiguity as to whether referring patients and families for these services was within nursing scope of practice. The vast majority of participants noted that they would refer patients themselves if there was a mandatory, nationally endorsed referral policy. These findings have implications for clinical practice and policy, and suggest that the formulation and implementation of robust national guidelines should be a priority. Because nurses would follow such guidelines, this might lead to an increase in donor rates and circumvent some uncertainty regarding referral. S Afr Med J 2017;107(7):573-575. DOI:10.7196/SAMJ.2017.v107i7.12487

Organ transplantation in South Africa (SA) began 50 years ago at the old Johannesburg Hospital in Hillbrow. Since then, advances in surgical technique and immunosuppressive agents have improved recipient and graft survival, so that transplantation is now accepted worldwide as standard of care for end-stage organ failure. In practice, however, access to organ transplantation is limited and inequitable in our country. Transplant services are not uniformly distributed, but rather confined to large urban areas in wealthier provinces. Nor is the service offered at each transplant centre standardised, with many more offering kidney than heart, lung, pancreas and liver transplants. There are also disparities across the state and private sectors. Socioeconomics and geography leave the poor in rural areas most vulnerable to exclusion. Having said this, we do have highly specialised transplant units that are grossly underutilised owing to persistently low organ-donor rates. Research has repeatedly shown that most South Africans across all population groups support organ donation. However, the public need more culturally and linguistically appropriate information to make informed decisions regarding organ donation.[1-3] Other potential reasons may be a lack of referral of potential donors by hospital staff and their attitudes towards donation. Again, local studies have confirmed that most trainee/qualified nurses and medical students are in favour of organ donation, and their stance is influenced more by education regarding organ donation than gender, cultural identity or ethnicity.[4-6] So why are our organ-donor rates still so frustratingly low? Low donation rates have been the focus of many international transplant communities. In countries where this has been successfully prioritised, some common themes emerge. These are: governmental support, comprehensive public education, clear clinical practice

guidelines, hospital staff education, an organ procurement transplant co-ordinator in each hospital and a ‘required referral’ system.[7,8] ‘Required referral’ means that any terminal patient who fulfils certain criteria must be timeously referred to a transplant co-ordinator for end-of-life care, irrespective of whether this results in organ donation. This may sound simple, but there is often conflict regarding how and when referral should take place. This conflict is understandable. Biomedicine has changed our definitions of death to include concepts such as imminent death, brain death and cardiac death. In addition, organ donation usually occurs in highly charged settings. For example, a ventilated intensive care unit (ICU) patient with a head injury has absent cranial nerve reflexes and a low Glasgow Coma Score, signifying risk of brain death. At what point should we refer a family for an end-of-life discussion? When there is imminent death, before or after testing for brainstem death, or when the attending clinician withdraws active treatment? Referral prior to withdrawal of care may feel unethical for some healthcare professionals. Bearing this in mind, how do the transplant co-ordinators maintain contact with the team? Should they assume a proactive role and call or email the unit daily, or should they join the team on a daily ward round? In the case of referral, who should then refer, the nurse caring for the patient or the primary doctor?[9] In this article we present the findings of a study in Johannesburg that was designed to go beyond the attitudes of nurses and explore end-of-life care and organ donation so that, at least in part, some of these issues may be addressed. In particular, we explored nurses’ knowledge of organ donation, and whether they would support clinical practice guidelines for end-of-life care and organ donation. Based on our findings, we discuss the potential implications for clinical practice and legislative regulation of organ donation in SA.

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Summary of the study

This study was conducted from July 2015 to March 2016 and was approved by the University of the Witwatersrand Human Research Ethics Committee (Medical) (ref. no. M150334). A total of 273 qualified nurses working in state and private sector ICUs, casualty and high-care departments, as well as two transplant units in Johannesburg, completed a self-administered questionnaire. Participation was similar in both state and private sectors, with an overall response rate of 68.6%. The majority (74.2%) of respondents were registered nurses, of whom 40.1% were ICU trained, and of the remaining staff, 56.5% had at least 1 year of ICU experience. Christianity (69.1%) and African Traditional Religion (16.5%) were the most common religious affiliations, and isiZulu (24.1%), English (13.8%) and Setswana (13.8%) were the most frequently spoken home languages. Our findings showed that most nurses (64.2%) were willing to donate their own organs after death. In addition, most nurses (63.2%) felt that their personal beliefs did not influence advice given to patients and families regarding organ donation, and this was independent of employment sector, age and qualification. The majority (85.9%) felt that end-of-life care should be offered to all terminally ill patients and their families, and (79.9%) that identifying these families was the role of the attending doctor. But less than half (47.6%) felt that staff in their unit communicated with families about end-of-life care, and only 45.4% felt that initiating these discussions was within their scope of practice. However, ICU-trained and registered nurses were more confident that this was within their scope of practice than enrolled nurses or nurse assistants. If there was a clear protocol supporting end-of-life discussions, 89.8% of nurses at all levels of training agreed they would follow it (Fig. 1). When asked about staff attitudes towards organ donation in their units, 36.8% of nurses agreed that staff viewed this positively, while a similar proportion were unsure (38.7%) and the remainder felt staff were negative (24.4%). Most nurses (84.5%) felt that referral for organ donation was the responsibility of the doctor. There was a roughly equal three-way split between nurses agreeing (35.8%), disagreeing (32.1%) and being unsure (32.1%) about whether organ-donor referral was within their scope of practice; ICU-trained and registered nurses felt more certain that organ-donor referral was within their scope of practice than other categories of nurses. As was seen with regards to the questions on end-of-

life care, 80.3% of all nurses, irrespective of employment sector, qualification, age or home language, would follow a clear protocol for organ-donor referral (Fig. 1). Regarding organ procurement, 61.0% of nurses were aware that there was access to a transplant co-ordinator through their hospital, but more nurses in the private sector (70.3%) were aware of this compared with those in the state sector (56.3%). The majority understood that the primary roles of a transplant co-ordinator included facilitating end-of-life care, tracing the family of a potential donor and consenting donor families, reminding staff about organ donation and teaching the community about organ donation. Nursesâ&#x20AC;&#x2122; knowledge regarding the supply of organs, access to transplants and legal rights of the donors/next of kin was fair, but there was a significant difference between those in the private sector, who had a better knowledge base, compared with the state sector, as there was with ICU-trained nurses when compared with non-ICU-trained colleagues. Those who were willing to donate their organs after death had better knowledge than those unwilling to donate. Their primary sources of information about organ donation were postgraduate workshops run by transplant co-ordinators, and active participation in the practical care of donors and/or recipients. Media, undergraduate training and exposure at school were considered less useful.

Discussion

This is the first quantitative study that has explored the perceptions of nursesâ&#x20AC;&#x2122; professional roles in the practice of endof-life care and organ donation in SA. The results show that overall, nurses support end-of-life care and organ donation, and if

there were clinical guidelines clarifying their roles, they would follow them. However, several issues are raised regarding current clinical practice. Firstly, in this study nurses recognised the need for and supported end-of-life care for all terminal patients. They also acknowledged that more than half of their units did not initiate end-of-life discussions, nor did they feel this was within their scope of practice. Similarly, only one-third of staff felt positive about the referral of potential organ donors, and almost the same proportion were unsure, while most felt this was outside their scope of practice. Understanding scope of practice in such a specialised field of medicine is difficult. Nursing scope of practice is legally defined within a certain set of parameters in SA. However, the specific roles required of nurses are not condensed into an exhaustive list because this would not account for changes in medical technology and procedures.[10] As a result, medical interventions such as organ transplant are not addressed in nursing scope-of-practice guidelines at all. Further compounding this uncertainty is the fact that currently there is no legislation, nor are there any clinical practice guidelines in SA that clarify the role of nurses in end-of-life care and organ donation. This may, in part, be the reason that nurses defer decision-making to the doctor. While the rationale for broad, nonspecific guidelines is understandable, end-of-life and organ donation issues present a unique set of interprofessional challenges, and their efficacy is based on multidisciplinary teamwork.[11] Without well-defined roles in these processes, nursesâ&#x20AC;&#x2122; unwillingness to participate is unsurprising. These types of regulatory issues have been addressed in other countries. In the UK, for example, best-practice guidelines outline the

If there was a clear protocol supporting end-of-life care discussions, do you think you would follow it? Is it within your scope of practice to have end-of-life discussions with patients and their families? If there was a clear protocol supporting organ donation, do you think you would follow it? Does your nursing scope of practice allow you to refer potential organ donors to the transplant co-ordinator? 0

100

Respondents, % Yes

Unsure

Fig. 1. Nurses' perceptions regarding scope of practice and willingness to follow protocols for end-of-life care and organ donation.

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IN PRACTICE

role of nurses, and endorse nurse-led referral of potential donors, provided minimum criteria for referral are met. These guidelines also offer potential avenues for the clinical team to interact with the transplant co-ordinators, which allows organ procurement personnel to engage in a predetermined manner with the primary clinical team. This prevents potential conflict and resistance from the primary clinical team in the referral process. Emphasis is placed on the importance of working as a team, in contrast to decisions and referrals being doctor driven.[9] In addition to being nationally endorsed at governmental level, each hospital in the UK is required to have its own policy in support of end-of-life care and organ donation, and to ensure ongoing education and training for staff in this area. This reinforces the role of each team member, allows staff to feel safe and facilitates the integration of end-of-life care and organ donation as standard daily practice, rather than as something extra that needs to be done. The second issue relates to education of nurses regarding organ donation. This study shows that knowledge of organ donation at school and in nurses’ undergraduate training contributes very little to their knowledge base. Rather, hands-on experience with organ donation once they were practising, and the ongoing efforts of organ procurement teams to promote understanding through informal workshops in hospitals, were much more effective learning opportunities. The third issue addresses the role of the organ-procurement team, through the transplant co-ordinator. At present, there is no formal training available for nurses who wish to specialise in organ procurement in SA. This prevents nurses from pursuing this area of specialty as a career path, and does not allow for specific training or a clear understanding of their roles. Currently, to work as a transplant co-ordinator in SA, it is generally accepted that ICU training is essential, and while some co-ordinators have completed specialised training overseas, this is not a standard requirement. Part of the success of teams elsewhere has been due to governmental commitment to support the appointment of a transplant co-ordinator in every hospital in the country that has the capacity to participate in organ donation.[7] While one may question the absence of similar governmental policy in SA, it is pertinent to consider whether we would have the capacity to train such staff, should the situation change. The last issue highlights the lack of standardisation of end-oflife care and referral of potential organ donors. Timeous referral of potential donors is essential to allow the transplant co-ordinator sufficient time to approach the grieving family, obtain consent, support the donor until organ procurement occurs and complete screening tests to ensure donated organs are transplantable. Currently, the referral process for potential organ donors to the procurement team is haphazard. While the attending doctor is responsible for the ‘medical’ diagnosis of death (brainstem or cardiac), is it appropriate or fair or in the best interests of the patient and their family to lay the sole responsibility for end-of-life care and organ donation entirely in the doctor’s hands? Failure to refer compromises the lives of thousands of patients with end-stage organ failure who are on waiting lists, and referral is regarded by some as an ethical obligation.[12] It may be that strongly doctor-centric models of practice are still very common in SA, but they are far less so in Europe and the USA. Could it be that our nurses feel disempowered, or fear recrimination from the attending doctor, rather than feeling part of a team in which their role is respected and valued? Do they fear litigation or consequences from their employer, particularly when there is no hospital policy to support their role? These factors deserve to be explored in future research.

Conclusion

This research adds some insight into nurses’ perceptions of their roles in end-of-life care and the referral of potential organ donors. It confirms that by far the majority of nurses would follow nationally endorsed clinical practice guidelines that address these important issues. These guidelines would need to determine definitions of death, criteria for referral for end-of-life care and organ donation, mechanisms of referral to the organ-procurement team, and the associated roles and responsibilities of both doctors and nurses. If nationally endorsed, and implemented at hospital level, this may improve organ-donor rates, and would be an essential precursor to any discussion on ‘required referral’ for SA. However, this cannot occur without simultaneously addressing the need to formalise the training of transplant co-ordinators within nursing education, and prioritising the lack of public education on organ donation. Dedication. This paper is dedicated to the memory of Belinda Rossi-Britz. Acknowledgements. We would like to acknowledge the following: Wits Donald Gordon Medical Centre; and REDCap (Research Electronic Data Capture) (Vanderbilt University, USA), a secure, web-based application designed to support data capture for research studies, providing: (i) an intuitive interface for validated data entry; (ii) audit trails for tracking data manipulation and export procedures; (iii) automated export procedures for seamless data downloads to common statistical packages; and (iv) procedures for importing data from external sources.[13] Author contributions. KC conceptualised and designed the study, consented participants, distributed questionnaires, and planned and edited the final manuscript. HE assisted with study design and provided insight on the final draft. JF assisted with study design and planned and wrote the manuscript. PG conducted the statistical design, piloted the questionnaire and edited the final manuscript. Funding. We thank Astellas Pharma (Pty) Ltd for funding. Conflict of interest. None.. 1. Bhengu B, Uys H. Organ donation and transplantation within the Zulu culture. Curationis 2004;27(3):24-33. 2. Pike RE, Odell J, Kahn D. Public attitudes to organ donation in South Africa. S Afr Med J 1993;83(2):91-94. 3. Etheredge HR, Turner RE, Kahn D. Attitudes to organ donation among some urban South African populations remain unchanged: A cross-sectional study (1993 - 2013). S Afr Med J 2014;104(2):133137. http://dx.doi.org/10.7196%2FSAMJ.7519 4. Naude A, Nel E, Uys H. Organ donation: Attitude and knowledge of nurses in South Africa. EDTNA ERCA J 2002;28(1):44-48. 5. Gidimisana ND. Knowledge and Attitudes of Undergraduate Nurses towards Organ Donation and Transplantation in a Selected Campus of a College in the Eastern Cape. Cape Town, South Africa: University of Cape Town, 2016. 6. Sobnach S, Borkum M, Millar AJ, et al. Attitudes and beliefs of South African medical students toward organ transplantation. Clin Transplant 2012;26(2):192-198. https://doi.org/10.1111/j.13990012.2011.01449.x 7. Bleakley G. Implementing minimum notification criteria for organ donation in an acute hospital’s critical care units. Nurs Crit Care 2010;15(4):185-191. https://doi.org/10.1111/j.14785153.2009.00385.x 8. Murphy F, Cochran D, Thornton S. Impact of a bereavement and donation service incorporating mandatory ‘required referral’ on organ donation rates: A model for the implementation of the Organ Donation Taskforce’s recommendations. Anaesthesia 2009;64(8):822-828. https://doi.org/10.1111/ j.1365-2044.2009.05932.x 9. Donor Identification and Referral Strategy Group, National Health Service Blood and Transplant. Timely Identification and Referral of Potential Organ Donors. A strategy for Implementation of Best Practice. National Health Service Blood and Organ Transplant Policy: United Kingdom, 2012. 10. Geyer N. Scope of nurses’ practice. Prof Nurs Today 2016;20(1):51-52. 11. Etheredge HR. ‘Hey sister! Where’s my kidney?’ – Exploring ethics and communication in organ transplantation in Gauteng Province, South Africa, 2015. http://hdl.handle.net/10539/21425 (accessed 17 January 2017). 12. Muller E. Organ donation and transplantation in South Africa – An update. CME J 2013;31(6):220-222. 13. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377-381. https://doi.org/10,1016/j. jbi.2008.08.010

Accepted 22 March 2017.

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IN PRACTICE

CASE REPORT

First report of clinical presentation of a bite by a running spider, Philodromus sp. (Araneae: Philodromidae), with recommendations for spider bite management M Coetzee,1,2 PhD; A Dippenaar,3 PhD; J Frean,1,2 MB BCh, MMed (Path); R H Hunt,1,2 PhD Wits Research Institute for Malaria, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Centre for Emerging, Zoonotic and Parasitic Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa 3 ARC-Plant Protection Research Institute, Pretoria; and Department of Entomology/Zoology, University of Pretoria, South Africa 1 2

Corresponding author: M Coetzee (maureen.coetzee@wits.ac.za)

This article describes the clinical progression of symptoms over a period of 5 days of a bite inflicted by a Philodromus sp. spider. Commonly known as ‘running spiders’, these are not considered to be harmful to humans. This report, however, is the first description of an actual bite by a member of this group of spiders showing cytotoxic envenomation. Management of the bites should be as recommended for other cytotoxic spider bites. S Afr Med J 2017;107(7):576-577. DOI:10.7196/SAMJ.2017.v107i7.12422

The effect of spider bites on humans is known for only a very few spider species in South Africa (SA), relative to the large number of species that occur in southern Africa and that very seldom come into contact with humans.[1] We report on the effects of a bite by a running spider in the genus Philodromus, commonly found in trees, shrubs and grass.

Case report

A 25-year-old woman sustained a spider bite on her left thumb on 8 May 2016 at 18h00, while taking down washing from a washing line in the garden. The bite was described as feeling like an ‘electric shock’ through the thumb and was extremely painful. Painkillers (tramadol hydrochloride/paracetamol) were taken to alleviate the symptoms. The spider was caught and later identified as a species of the genus Philodromus (Araneae: Philodromidae), commonly known as running spiders (Fig. 1).

At 09h00 on 9 May, the thumb was still extremely painful and blisters had started to appear (Fig. 2, A). Two faint puncture marks were visible below the first blister, which appeared above the actual site of the bite. At 15h00 on 9 May, three blister areas were clearly visible (Fig. 2, B), not associated with the bite site, and the thumb was still extremely painful. On 10 May, 40 hours after the bite, two puncture marks were clearly visible below the upper blister but no new blistering had appeared (Fig. 2, C) and the toxic effects had not spread further down the thumb towards the palm. Pain had subsided, but the thumb was sensitive to touch. Later on 10 May, 45 hours after the bite, the upper blister area showed subepithelial haemorrhagic necrosis and the puncture marks were clearly visible (Fig. 2, D). The pain had subsided and painkillers were no longer needed. On 11 May, 68 hours after the bite, the blister on the outer side of thumb was no longer visible but the puncture marks were still clearly seen. Necrosis of the upper blister had not progressed, and there was no ulceration (Fig. 2, E). On 13 May, 112 hours after the bite, the upper blister area had started healing and the lower blister was no longer visible, but the puncture marks were still clearly seen (Fig. 2, F). Case management and treatment was according to best practice as recommended for cytotoxic spider bites, i.e. prevention of secondary infection.[2-4]

Discussion

Fig. 1. Species of running spider of the genus Philodromus, captured after biting.

Philodromid spiders are free-living hunters. They capture their prey by lying in ambush with extended legs. Their movements are erratic, and with their claw tufts and scopulae they are able to move around swiftly on the substrate. They usually run fast and pursue their prey with agility. Most have cryptic coloration blending in with their surroundings. Their colour varies from white to pale cream and from reddish brown to greyish brown, frequently with a mottled appearance or longitudinal bands or chevrons on the

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abdomen. Their bodies are slightly flattened and clothed with soft recumbent setae. The eight eyes, equal in size, are arranged in two rows (4:4). The legs are directed sideways, with legs I, III and IV almost the same length and leg II usually longer. Their body size can vary from 3 to 16 mm in length.[1] Ten species of the genus Philodromus are known in SA. They are free-living plant dwellers found on the trunks of trees and in low bushes and herbage, where they play an important role as biological control agents feeding on different pest species. They are not commonly found in houses or buildings. This is the first reported bite in SA by a member of the family Philodromidae. Avoidance of spider bites relies mainly on common sense, awareness and an understanding of their behaviour. The common spiders of medical importance in SA are listed in Table 1, with a summary of their key attributes.[1,5-7] Acknowledgements. The patient consented to publication of this case report and the thumb photographs. Author contributions. Analysis of clinical progression was given by JF, MC and RHH. AD identified the spider and gave input on biology and importance. All authors gave substantial input to draft manuscripts and all approved the final version. Funding. None. Conflicts of interest. None.

Fig. 2. Progression of the clinical symptoms of the spider bite. (A) 9 May, 15 hours after the bite – two puncture marks are faintly visible below upper blister area; (B) 9 May, 21 hours – three blister areas clearly visible, apparently not associated with the bite site; (C) 10 May, 40 hours – two puncture marks below upper blister now clearly visible; (D) 10 May, 45 hours – upper blister area appearing necrotic, puncture marks clearly visible; (E) 11 May, 68 hours – all symptoms subsided but two blisters and the puncture marks still clearly visible, blister on outer side of thumb no longer visible; (F) 13 May, 112 hours – only the upper blister and puncture marks still visible.

1. Dippenaar-Schoeman AS. Field Guide of the Spiders of South Africa. Pretoria: Lapa Publishers, 2014:1-424. 2. Snyman C, Larsen N. Spider bite and its treatment in southern Africa. Occup Health South Afr 2005;11(2):22-26. 3. Műller GJ, Wium CA, Marks CJ, et al. Spider bite in southern Africa: Diagnosis and management. CME 2012;30(10):382-392. 4. Schrire L, Müller GJ, Pantanowitz L. The Diagnosis and Treatment of Envenomation in South Africa. Johannesburg: South African Institute for Medical Research, 1996:1-51. 5. Newlands G, Atkinson P. Review of southern African spiders of medical importance, with notes on the signs and symptoms of envenomation. S Afr Med J 1988;73(2):235-239. 6. Newlands G. Spiders and Scorpions of Southern Africa. Cape Town: Struik, 1987:1-26. 7. Müller GJ. Black and brown spider bites in South Africa: A series of 45 cases. S Afr Med J 1993;83(6):399-405.

Accepted 9 March 2017.

Table 1. Spiders of medical importance in South Africa Usual habitat, e.g. in/outdoors, peridomestic

Key identifying features

Geographical distribution

Black button spiders/ black widow spiders Theridiidae Latrodectus spp.

Black/brown with red markings on or under the abdomen

Four spp. occurring in Not so common in different areas houses, found in the field and crops

Brown button spiders Theridiidae Latrodectus geometricus

Name of spider

Type of toxin, i.e. cytotoxic, neurotoxic

Clinical management

Neurotoxic

Antivenom, treatment of symptoms (pain, cramps, fever, nausea, vomiting, etc.)

Cream to black with Widespread introduced Under windowsills red hourglass marking species or garden furniture, under abdomen behind drain pipes, in outside toilets

Neurotoxic (less venomous than black button)

Antivenom only sometimes needed, treatment of symptoms (pain, cramps, fever, nausea, vomiting, etc.)

House sac spiders Eutichuriidae Cheiracanthium furculatum

Cream with shiny black Widespread mouthparts

Often found indoors in folds of curtains or door frames

Cytotoxic

Extensive erythema or necrosis. Prevention of secondary infection

Violin spiders Sicariidae Loxosceles spp.

Brownish with violinshaped markings on the carapace

Found in dark places indoors, behind pictures or boxes, in clothing or shoes

Cytotoxic

Extensive erythema and necrosis. Prevention of secondary infection is critical

Different spp. with restricted distribution

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IN PRACTICE

CASE REPORT

Blistering rash in a young male child C Sanders, MB ChB; H Potgieter, MD, FCPaed Paediatrics Department, Leratong Hospital, Johannesburg, South Africa Corresponding author: C Sanders (cathrynsand@gmail.com)

A 3-year-old child was brought to the casualty department at Leratong Hospital, Johannesburg, South Africa, with severe bullous eruptions on the distal portions of both the upper and lower limbs. He had visited three different general practitioners prior to presentation and had been given several drugs and ointments, including three different classes of antibiotics. During his admission, the diagnosis of linear IgA bullous dermatitis was made. Dapsone and prednisone were given and he recovered well. S Afr Med J 2017;107(7):578-580. DOI:10.7196/SAMJ.2017.v107i7.12407

Linear IgA bullous dermatosis (LABD) is an autoimmune skin disorder in which blisters form as a result of a split between the epidermis and dermis. The first cases of LABD date from 1901 - 1905, when it was still considered to be part of the spectrum of dermatitis herpetiformis. Only 80 years later was it recognised as a distinct clinical entity.[1] IgA autoantibodies react to components of the hemidesmosomes and basement membrane.[2] The blisters are classically tense, indicating that they are of subepidermal origin as opposed to the flaccid bullous lesions of epidermal origin.[3] The name LABD arises from the finding of a line of IgA antibodies below the epidermis on immunofluorescence examination of a skin biopsy specimen.[3]

Case report

A 3-year-old boy was brought to the emergency department at Leratong Hospital, Johannesburg, South Africa, with a 1-week history of progressively worsening blisters on his arms and legs. He was unexposed to HIV and had previously been well, with no prior hospital admission. Two weeks before the appearance of the rash, the patient had suffered from a fever and vomiting. His mother took him to a private general practitioner (GP), who prescribed cyclizine (an antiemetic), Goldgesic syrup (mainly paracetamol), amoxicillin plus clavulanic acid, and a co-trimoxazole suspension. After the patient had been on the above treatment for about 3 days, his mother noticed a rash comprising small blisters on his arms and legs. A different GP was consulted, who prescribed griseofulvin, retapamulin ointment, Tetmosol soap, cloxacillin and chlorpheniramine maleate, with no advice to stop the previously prescribed drugs. The rash got progressively worse, so when the mother took the child to a third GP, she was advised to take him to hospital. On presentation to Leratong Hospital the patient was well, with vital signs within normal limits and no remarkable findings on systemic examination. On examination of the skin, tense, deep bullae with surrounding vesicles on an erythematous base were present on the distal extremities. There were areas of central necrosis and a tendency to coalesce (Fig. 1). The mucous membranes were not involved and the palms and soles were spared. Around the left wrist and right lower limb, the lesions had formed a ‘string of pearls’ sign (Fig. 1). There

Fig. 1. The lesions on presentation, including the ‘string of pearls’ sign (white arrow).

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IN PRACTICE

Fig. 2. Clinical improvement after 1 week’s treatment with prednisone and dapsone.

were a few smaller vesicular lesions on the lower abdomen and around the anus. The patient complained that the lesions were itchy, and the lesions around his anus were painful, making it difficult for him to pass a stool. The patient was admitted and assessed as suffering from a possible drug reaction. All medication was stopped and he was referred to the Dermatology Department at Baragwanath Hospital for consultation and a biopsy. The dermatologist’s differential diagnosis was LABD, followed by bullous erythema multiforme. The treatment given was a combination of prednisone and dapsone, as well as topical steroids and emollients to use on the affected areas. The patient responded well to treatment, with the lesions showing vast improvement after 1 week of the prescribed medication (Fig. 2). The patient was followed up at the Leratong outpatient department, and 6 months after the initial presentation the lesions had almost completely healed, with evidence of post-inflammatory hyperpigmentation (Fig. 3). Review of the histological findings and direct immunofluorescence examination confirmed the diagnosis of linear IgA bullous dermatosis, an intact skin punch biopsy showing 1 - 2+ linear staining in the region of the epidermal basement membrane.

Discussion

Linear IgA dermatosis is a rare autoimmune bullous disease, yet the most common autoimmune bullous disease in children.[1] The aetiological factor triggering the autoimmune mechanism of the disease is unknown.[1]

Fig. 3. Almost complete healing 6 months after initial presentation.

The typical clinical presentation of LABD is of small vesicles or bullae, which are annular and may develop into a target shape. There is a tendency for new vesicles to form in a ring around the old lesion, giving the ‘string of beads/pearls’ sign, which was present in our patient. It may be difficult to distinguish LABD clinically from dermatitis herpetiformis. They are both blistering diseases and on immunofluorescence microscopy show evidence of IgA deposition; however, dermatitis herpetiformis is associated with a gluten-sensitive enteropathy (coeliac disease).[4] The presentation of LABD can follow a viral illness or exposure to a drug. The most frequently associated drugs include vancomycin, diclofenac and co-trimoxazole, but the most consistent association described in the literature is with vancomycin.[1,3,5] The diagnosis is made on examination of a skin biopsy specimen, where an infiltration of neutrophils and eosinophils is seen under the epidermis. Direct immunofluorescence examination reveals IgA along the basement membrane in a linear pattern. Most cases reported in the literature had a similar outcome to that in our patient, complete remission being achieved following a course of prednisone and dapsone.[1] One such case report described a 10-month-old white child with LABD with a similar presentation to

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IN PRACTICE

our patient, but with no fever or mucosal signs. However, in contrast to our case, there was no causal relationship with drug exposure or viral illness to explain the occurrence of the lesions.[1] In a similar case report, where an infant developed LABD but failed to respond to prednisone, mycophenolic acid was used with a good clinical outcome.[6] This drug should be used with caution, however, as it can have adverse effects such as myelosuppression, infections and severe diarrhoea. When dapsone is contraindicated, e.g. in patients with glucose-6phosphatase dehydrogenase deficiency, haemolytic anaemia or severe bone marrow suppression, LABD has been successfully treated with flucloxacillin with a decreased incidence of remission, provided the treatment was started early on in the course of the disease.[7]

Conclusion

This case illustrates the importance of knowing about LABD, the differential diagnosis of which includes bullous disease of childhood and erythema multiforme. It also highlights the danger of prescribing a ‘shopping list’ of drugs/antibiotics, which makes it difficult to identify the offending drug if an adverse drug reaction does develop. It also emphasises the importance of timeous referral to appropriate

specialist support for early recognition, relevant special investigations and treatment of unusual clinical presentations. Acknowledgements. None. Author contributions. Written by CS, with contributions from HP. Funding. None. Conflicts of interest. None. 1. De Souza BC, Tebcherani A. Linear IgA bullous dermatosis: Report of an exuberant case. An Bras Dermatol 2013;88(6 Suppl 1):S67-S70. http://doi.org/10.1590/abd1806-4841.20132154 2. Burge S. Oxford Handbook of Medical Dermatology. 1st ed. London: Oxford, 2011. 3. DermNet New Zealand. Linear IgA bullous disease. 2015. www.dermnetnz.org/topics/linear-igabullous-disease (accessed 11 November 2016). 4. Kirtschig G, Wojnarowska F. Autoimmune blistering diseases: An up-date of diagnostic methods and investigations. Clin Exp Dermatol 1994;19(2):97-112. http://doi.org/10.3238/arztebl.2011.0405 5. Nousari HC, Kimyai-Asadi, A, Caeiro JP, et al. Clinical, demographic and immunohistological features of vancomycin induced linear IgA bullous disease of the skin: Report of two cases and review of the literature. Medicine (Baltimore) 1999;78(1):1-8. 6. Farley-Li J, Mancini A. Treatment of linear IgA bullous dermatosis of childhood with mycophenolate mofetil. Arch Dermatol 2003;139(9):1121-1124. http://doi.org/10.1001/archderm.139.9.1121 7. Alajlan A, Al-Khawajah M, Al-Sheikh O, et al. Treatment of linear IgA bullous dermatosis of childhood with flucloxacillin. J Am Acad Dermatol 2006;54(4):652-656. http://doi.org/10.1016/j. jaad.2005.11.1102

Accepted 14 March 2017.

July 2017, Print edition

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RESEARCH

Inefficient procurement processes undermine access to medicines in the Western Cape Province of South Africa B P Magadzire,1 BSc, MPhil; K Ward,2 BPharm, MPharm, PhD; H M J Leng,1 MPharm, PhD, MBA; D Sanders,1 MB ChB, MRCP, DCH, DTPH, DSc (Hon Causa) 1 2

School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa School of Pharmacy, Faculty of Natural Sciences, University of the Western Cape, Cape Town, South Africa

Corresponding author: B P Magadzire (bmagadzire@gmail.com) Background. South Africa (SA) has experienced several stock-outs of life-saving medicines for the treatment of major chronic infectious and non-communicable diseases in the public sector. Objective. To identify the causes of stock-outs and to illustrate how they undermine access to medicines (ATM) in the Western Cape Province, SA. Methods. This qualitative study was conducted with a sample of over 70 key informants (frontline health workers, sub-structure and provincial health service managers). We employed the critical incident technique to identify significant occurrences in our context, the consequences of which impacted on access to medicines during a defined period. Stock-outs were identified as one such incident, and we explored when, where and why they occurred, in order to inform policy and practice. Results. Medicines procurement is a centralised function in SA. Health service managers unanimously agreed that stock-outs resulted from the following inefficiencies at the central level: (i) delays in awarding of pharmaceutical tenders; (ii) absence of contracts for certain medicines appearing on provincial code lists; and (iii) suppliersâ&#x20AC;&#x2122; inability to satisfy contractual agreements. The recurrence of stock-outs had implications at multiple levels: (i) health facility operations; (ii) the Chronic Dispensing Unit (CDU), which prepacks medicines for over 300Â 000 public sector patients; and (iii) community-based medicines distribution systems, which deliver the CDUâ&#x20AC;&#x2122;s prepacked medicines to non-health facilities nearer to patient homes. For instance, stock-outs resulted in omission of certain medicines from CDU parcels that were delivered to health facilities. This increased workload and caused frustration for frontline health workers who were expected to dispense omitted medicines manually. According to frontline health workers, this translated into longer waiting times for patients and associated dissatisfaction. In some instances, patients were asked to return for undispensed medication at a later date, which could potentially affect adherence to treatment and therapeutic outcomes. Stock-outs therefore undermined the intended benefits of ATM strategies. Conclusion. Addressing the procurement challenges, most notably timeous tender awards and supplier performance management, is critical for successful implementation of ATM strategies. S Afr Med J 2017;107(7):581-584. DOI:10.7196/SAMJ.2017.v107i7.11356

Medicines shortages (stock-outs) have been cited as a complex global problem. Evidence suggests that the causes vary greatly and include issues that government agencies often do not have control over, such as supplier shortages.[1] Stock-outs appear to be worsening with time globally, which presents a threat to patient wellbeing and could result in loss of life.[2] At a global level, multi-stakeholder activities to evaluate the causes of stock-outs and to develop appropriate mitigating strategies have been initiated.[2] Like many other countries, South Africa (SA) has experienced several stock-outs of life-saving medicines. There has also been a spate of media reports on stock-outs of essential medicines for treatment of HIV and major chronic non-communicable diseases.[3,4] A 2012 publication by the National Department of Health (NDoH) [5] reported a 54% failure in compliance with measures addressing availability of medicines and recommended priority attention to supply chain management. Local research has found that confidence in the public sector has waned as a result of stock-outs.[6] These and other ongoing challenges in the SA medicines supply chain served as the impetus to investigate the supply chain and to identify barriers to access to medicines (ATM) and existing strategies for improving ATM under the Accessing Medicines in Africa and South Asia project.[7] In this quest, we acknowledged that ATM

barriers are multi-layered, with overlapping and interconnected causes,[2,8] and that the supply chain in SA is diverse and complex. Notwithstanding these complexities, it is expected to reliably supply pharmaceuticals from manufacturers to provincial depots and subdepots (in some cases), and directly or indirectly to all levels of health facilities, centralised dispensaries and other non-health facilities. This is crucial for meeting the growing demand for medicines, particularly for treatment of chronic diseases, among others.[9] Given the various interconnections in the supply chain, our approach was to investigate how the complex interplay of ATM dimensions, including pharmaceutical regulation, medicines distribution and demandside barriers, influenced ATM in SA. We selected tracer medicines commonly used in the public sector that could aid in identifying the relevant issues in the supply chain. These were rifampicin (antituberculosis), metformin (antidiabetic, type 2), lamivudine (antiretroviral), fluoxetine (antidepressant) and oxytocin (labour induction).[7] Previous articles emanating from this research reported on policy implications for medicine registration[10] and equity in the geographical distribution of community pharmacies in SA.[11] We also identified supply and demand barriers to ATM[12] and existing strategies for mitigating these barriers.[12,13] In the Western Cape

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RESEARCH

(WC) Province, we identified two distinct strategies for improving ATM: the Chronic Dispensing Unit (CDU) and community-based medicines delivery models. The CDU, a model for centralised dispensing of medicines in the public sector, was introduced to address the shortage of pharmacists, reduce patient waiting times and decongest health facilities.[13-15] Community-based medicines delivery models were aimed at distributing medicines closer to patients’ homes, thereby addressing barriers associated with physical accessibility and affordability of transport costs. These models are fully described elsewhere.[16-18] Despite these advances in the WC, public sector stock-outs hampered the efficiency of ATM strategies and disrupted service provision. Among the reasons offered for stock-outs were inefficiencies in procurement, a centralised function. In this article we therefore demonstrate how inefficient procurement processes have undermined ATM.

Medicines procurement in SA

Procurement of medicines in SA is centralised and managed by the NDoH, with some variation in organisation between procurement of HIV medicines and that of other medicines. Pharmaceutical tenders are advertised, awarded and monitored by the NDoH. Provinces submit quantification figures to the NDoH for the contract period, where the figures are then aggregated. Contracted suppliers deliver directly to depots and in some cases (for selected items) directly to the CDU and health facilities.

Methods

This qualitative study was conducted between 2012 and 2014 with a purposeful sample of over 70 key informants representing frontline health workers, sub-structure and provincial level health service managers.

Application of the critical incident technique

We employed the critical incident technique[19] to identify occurrences that have special significance in our context. The method focuses on gathering data that are potentially useful in solving practical problems. Critical incidents were described by Flanagan[19] as: • an extreme behaviour, either outstandingly effective or ineffective with respect to attaining the general aims of an activity • an incident that is complete in itself to permit inferences and predictions to be made, and the consequences of which are sufficiently definite to leave little doubt concerning its effects. In this research, the critical incident was defined as any such incident having special significance in our context. Data collection. The critical incident technique consists of a set of procedures for collecting information that allow participants to ‘tell the story’ (what) and then generate details by posing probing ‘when’, ‘where’ and ‘why’ questions. The technique is commonly used to collect data on observations previously made that are reported from memory – which is usually satisfactory when the incidents reported are fairly recent. However, in some situations adequate coverage cannot be obtained if only very recent incidents are included.[19] As such, we requested the informants to reflect on a longer period (5 years) to identify incidents positively or negatively affecting ATM. To allow for this detailed exploration, we used a semi-structured interview guide containing open-ended questions as a data collection tool. Data analysis. Our process involved listing the incidents identified, then making a judgement based on the principles of the critical incident technique as described earlier. We then developed descriptions of the selected incidents.

Ethics approval and consent to participate

Ethics approval for this study was granted by the Senate Research Committee of the University of the Western Cape (ref. no. 11/7/8). Consent to interview and record interviews was obtained from participants. They were also informed of their right to withdraw from the interview at any time.

Results

Overview of the general state of medicines availability in the WC

Informants recognised the positive role by the WC Department of Health in instituting measures to minimise stock-outs in the province. They reported that in general, stock-outs at the provincial depot had reduced significantly from over 160 out-of-stock items each week a few years before to an average of 10 - 20 items at the time of the study, some of which could be substituted by the use of different pack sizes of the same medicine. Frontline health workers received regular updates on the stock situation from the depots, which enabled them to make alternative arrangements where possible. Sometimes buffer stock was available in the health facilities, enabling pharmacists to continue dispensing activities without disruption in the event of stock-outs at the depot. However, poor forecasting at the level of health facilities was sometimes regarded as a challenge, particularly during times of policy changes or strategic service delivery decisions that led to increased demand for specific medicines and medical devices without the necessary adjustments to the quantification and ordering processes. Such events occurred when health managers developed programmes or campaigns and neglected to liaise timeously with the provincial supply chain team, which could in turn result in stock-outs. One such incident was described by a pharmacy manager as follows: ‘… last month we had a problem with Accu-check sticks [for blood glucose testing] because the province started testing everyone for glucose and nobody told the depot “Listen, we need more …”, and the depot didn’t know to tell the company [supplier], so now we’ve got this snowball effect and … we don’t have enough to give the patient.’ Although the above example referred to medical devices, similar experiences occurred with tracer medicines, and the informant raised it in that context. Besides province-specific issues, processes at central level caused stock-outs at particular time periods. Two of our tracer medicines, i.e. metformin and rifampicin, were affected by these processes, and so were other medicines. This in turn had implications for ATM.

Perceived causes of procurement inefficiencies

Stock-outs were attributed to: (i) delay in award of pharmaceutical tenders; (ii) removing national contracts for certain medicines on provincial code lists; and (iii) supplier failure to meet contract obligations. We elaborate on these three factors below, and discuss the implications of stock-outs for ATM strategies in the WC. Delay in award of pharmaceutical tenders Delayed award of pharmaceutical tenders by the NDoH emerged as one of the key challenges facing the pharmaceutical system. Some informants attributed tender challenges to a lack of manpower in the NDoH to timeously renew tenders – a function previously performed by National Treasury. During our research, we witnessed the knockon effect of late tender awards in 2012 and 2014. Informants reported that this was a common occurrence every 2 years when

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pharmaceutical contracts expired. By 2014, some informants had witnessed the impact of late tender awards over a number of cycles, which led to an increase in the number of out-of-stock items. As indicated by one informant: ‘… we had dues out [out-of-stock medicines] down to about 10 to 15 at one stage for quite a long period at depot side. Now it’s started creeping up to 60 … in a crisis 2 years ago it was over 100. But it is on the increase because of these tender problems.’ (Senior provincial manager) Another informant added: ‘Every 2 years when the contracts expire we go through these (stock) problems … at the moment we’re sitting with a 66 item dues-out at depot [medicines unavailable from the depot], and this is because of the tendering system … And that’s the biggest gap in the system … they [the NDoH] know exactly when the tender is going to end, but the process takes so long. Then they have to ask current tender companies to extend their contract for 1 or 2 months. The company’s response could be, “I don’t want to do it, and I don’t have the capacity.” Then they have to look for another company and this usually leads to problems.’ (Mid-level manager, district substructure) In an effort to understand reasons for suppliers’ unwillingness to extend contracts, one informant shared the following insights: ‘I think there is a lack of understanding with our tender guys [procurement officials] that these pharmaceutical manufacturers sometimes plan 2 years in advance. And when they plan, when they have been allocated the contract that obviously has a major impact on their production planning – and we must remember that they don’t produce only one item or two items, they’ve got a variety of products that they manufacture. They have timeslots and certain machines for all these, and one machine might be used for two different products. So there are major challenges for them as well, but from a planning point of view it really has a negative effect on these guys [suppliers].’ (Mid-level manager, medicines procurement) Informants also added that suppliers tend to downscale production in the last few months of their contract because of uncertainties around successful rebidding. In view of the tough economic climate, it is no longer financially viable for suppliers to produce excess stock, whereas in the past they held significant amounts of buffer stock, allowing them the flexibility to extend their contracts. Suppliers are also sometimes reluctant to extend their contracts because of the unplanned production upscaling and the associated risk of being penalised should they fail to meet the prescribed timelines. Interim options to source large volumes of medicine from alternative pharmaceutical companies that are not contracted to the NDoH are limited, since these companies tend to downscale manufacturing of a particular medicine if they fail to secure a national contract. Absence of national contracts for medicines on the provincial code list According to informants, at times there was poor communication between provincial and national stakeholders. A case in point: about 70 items were excluded from the most recent national tender at the time of the study (2014) without first consulting provinces, which was the usual practice in order to allow health providers to prepare for the change. Informants thought this action was a result of efforts by the NDoH to align medicines tenders to the Essential

Medicines List. At the same time, a decision was taken to include only one item per medicine class, which placed a strain on the industry to increase production of these items and also meant that there were no alternatives for the provinces in the event of shortages. While provinces could lobby for the medicines to be placed back on national tender and/or to procure directly from suppliers (sometimes involving importation of medicines), these processes often took a long time, with resultant delays in supply. In other cases, guideline modification through the Provincial Pharmacy and Therapeutics Committees was required to allow for medicines substitution. The positive note reported by our informants was that the NDoH acknowledged the risk of only including one item per class. Failure by suppliers to meet demand Suppliers failed to meet contractual obligations due to: (i) global shortages of active pharmaceutical ingredients (APIs) (e.g. the shortage of APIs for antituberculosis medicines during the study period); and (ii) lack of capacity, especially during the start-up phase, after a contract is awarded, when demanders procure large volumes to compensate for stock-outs imposed by delayed contracting. General capacity constraints also became evident during the course of the contract when a supplier failed to meet demands, and although these incidents were reported to the NDoH, it was not unusual for the contractor to be reappointed during the next tender cycle. One informant said: ‘We are tied [left with no option] … the most we can do is inform the National Department of Health that they have been bad suppliers … but history has shown us and our experience has shown us that those suppliers do get reappointed with contracts again and we sit with the same problems again.’ (Midlevel manager, medicines procurement) When a supplier provides a substandard/inferior product and a medicine recall ensues, a severe disruption in supply may result. An incident cited by informants was when the state received supplies of rifampicin tablets containing substantially less than the specified amount of active ingredient.

Implications of stock-outs for ATM strategies

Strategies for improving ATM in the WC were affected by stock-outs. First, the CDU system, which dispenses medicines for over 300 000 patients, operates on a set production schedule and stock received after commencement of the production process cannot be introduced into the dispensing system. Stock-outs resulted in batches of patient medicine parcels (PMPs) being dispatched to health facilities without all the prescribed medicines. Consequently, pharmacists at health facilities manually dispensed the missing medicines from buffer stock or provided alternative therapy under the authorisation of a prescriber. Owing to the high burden of chronic diseases in the province, this meant that several hundreds of PMPs at each health facility required additional medicines. While it was commendable that health facilities sometimes had buffer stock that allowed them to minimise the impact of stock-outs on patients, workload in the pharmacies increased due to the additional dispensing tasks and caused frustration among pharmacists. Accordingly, patient waiting times increased. In instances where no buffer stock was available, patients had to return at a later date when the medicine was expected to be available. Also, community-based services rely on the CDUs’ prepacked PMPs, and these services were affected when stock-outs occurred. Stock-outs caused service interruption, forcing patients who benefited from community-based services to attend the health

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facility for their medicine supply. This imposed additional transport costs on patients and is likely to have impacted negatively on their welfare. Stock-holding at depots (up to 6 months) and health facilities (4 - 8 weeks) generally created a buffer to procurement and other challenges in medicine supply, ensuring that patients had access to their medicines. In recognising the importance of maintaining buffer stock, there were some concerns that the recommendation from the NDoH for the public sector to migrate to a ‘push’ model, which supplies pre-defined and standard volumes of medicine down to health facilities based on demand planning, as opposed to a ‘pull’ model, which relies on orders from health facilities, could preclude holding buffer stock.

Discussion

The challenges imposed by stock-outs are becoming more evident against the backdrop of increased demand for chronic disease treatment in SA,[20] but they are not new.[21] While some studies have reported that pharmaceutical systems in low- and middle-income countries are generally strained and weak,[22-24] there has been a limited focus on procurement processes, yet the critical incidents identified in our study were linked to this issue. The interconnected nature of different levels of the health system (provincial and national) was clear. Based on the issues raised by this research, minimising stock-outs requires action at a national level, where procurement takes place, to ensure that tenders are awarded timeously and supplier performance is monitored. Also, the provinces (not only the WC) have a responsibility to provide accurate forecasts to the NDoH. Existing ATM strategies[13-17] depend on a consistent, secure and reliable source of medicines to function optimally, yet they are regularly interrupted by stock-outs. Addressing the prevailing challenges will be of benefit to the country as a whole given that medicines will continue to play an integral role in the health system, not only of the individual provinces but also to achieve the ATM goals under the proposed National Health Insurance scheme in SA.[25]

Conclusion

Addressing causes of stock-outs, starting at the national level, is critical for successful implementation of ATM strategies in SA and to ensure that patient care is not adversely affected. The recurrence of stock-outs due to predictable events warrants continued attention to the underlying issues. Addressing the procurement challenges, most notably timeous tender awards and supplier performance management, is critical for successful implementation of ATM strategies. Acknowledgements. We thank the Western Cape Department of Health for allowing us to learn from their experience. Author contributions. KW, HMJL and DS contributed to the conceptualisation of the research. KW, HMJL and BPM conducted the field research. All authors contributed to the conceptualisation of the manuscript. BPM undertook qualitative data analysis and drafted the manuscript. All authors contributed to the intellectual content of the article. BPM finalised the article. All authors read and approved the final manuscript.

Funding. This research and the involvement of co-authors was made possible by funding from the European Union Seventh Framework Programme Theme: Health-2009-4.3.2-2 (grant no. 242262) under the title ‘Accessing Medicines in Africa and South Asia’, which was concluded in 2013. Subsequent work was made possible by the first author’s doctoral funding from the South African Research Chair Initiative in Health Systems, Complexity and Social Change at the University of the Western Cape, the Belgian Development Cooperation and an African Doctoral Dissertation Research Fellowship award offered by the Africa Population and Health Research Centre in partnership with the International Development Research Centre. Conflicts of interest. None. 1. Gray A, Manasse HR jun. Shortages of medicines: A complex global challenge. Bull World Health Organ 2012;90(3):158-158A. http://dx.doi.org/10.2471/BLT.11.101303 2. International Pharmaceutical Federation (FIP). Report of the International Summit on Medicines Shortage. Toronto: FIP, 2013. 3. Gray A. Medicines shortages – unpicking the evidence from a year in South Africa. Australas Med J 2014;7(5):208-212. http://dx.doi.org/10.4066/AMJ.2014.1932 4. Bateman C. Drug stock-outs: Inept supply-chain management and corruption. S Afr Med J 2013;103(9):600-602. http://dx.doi.org/10.7196/SAMJ.7332 5. Health Systems Trust. The National Health Care Facilities Baseline Audit: National Summary Report. Durban: HST, 2012. 6. Goudge J, Gilson L, Russell S, Gumede T, Mills A. Affordability, availability and acceptability barriers to health care for the chronically ill: Longitudinal case studies from South Africa. BMC Health Serv Res 2009;9(1):75. http://dx.doi.org/10.1186/1472-6963-9-75 7. Accessing Medicines in Africa and South Asia project. http://www.amasa-project.eu/ (accessed 12 May 2016). 8. Bigdeli M, Jacobs B, Tomson G, et al. Access to medicines from a health system perspective. Health Policy Plan 2013;28(7):692-704. http://dx.doi.org/10.1093/heapol/czs108 9. Deuboué Tchialeu RI, Yaya S, Labonté R. Health systems readiness to manage the hypertension epidemic in primary health care facilities in the Western Cape, South Africa: A study protocol. JMIR Res Protoc 2016;5(1):e35. http://dx.doi.org/10.2196/resprot.5381 10. Leng HMJ, Sanders D, Pollock AM. Pro-generics policies and the backlog in medicines registration in South Africa: Implications for access to essential and affordable medicines. GaBI J 2015;4(2):58-63. http://dx.doi.org/10.5639/gabij.2015.0402.014 11. Ward K, Sanders D, Leng H, Pollock AM. Assessing equity in the geographical distribution of community pharmacies in South Africa in preparation for a national health insurance scheme. Bull World Health Organ 2014;92(7):482-489. http://dx.doi.org/10.2471/BLT.13.130005 12. Magadzire BP, Budden A, Ward K, Jeffery R, Sanders D. Frontline health workers as brokers: Provider perceptions, experiences and mitigating strategies to improve access to essential medicines in South Africa. BMC Health Serv Res 2014;14(1):520. http://dx.doi.org/10.1186/s12913-014-0520-6 13. Magadzire BP, Marchal B, Ward K. Improving access to medicines through centralised dispensing in the public sector: A case study of the Chronic Dispensing Unit in the Western Cape Province, South Africa. BMC Health Serv Res 2015;15(1):513. http://dx.doi.org/10.1186/s12913-015-1164-x 14. Du Plessis J. The Chronic Dispensing Unit. S Afr Pharm J 2008;75(9):46-47. 15. Du Toit J, Dames S, Boshoff R. Centralised dispensing – an affordable solution. S Afr Pharm J 2008;75(10):18-20. 16. Grimsrud A, Sharp J, Kalombo C, Bekker LG, Myer L. Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa. J Int AIDS Soc 2015;18(19984):19984. http://dx.doi.org/10.7448/IAS.18.1.19984 17. Wilkinson LS. ART adherence clubs: A long-term retention strategy for clinically stable patients receiving antiretroviral therapy. South Afr J HIV Med 2013;14(2):48-50. http://dx.doi.org/10.7196/ SAJHIVMED.924 18. Luque-Fernandez MA, van Cutsem G, Goemaere E, et al. Effectiveness of patient adherence groups as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PLoS One 2013;8(2):e56088. http://dx.doi.org/10.1371/journal.pone.0056088.g001 19. Flanagan J. The critical incident technique. Psychol Bull 1954;51(4):327-358. http://dx.doi.org/10.1037/ h0061470 20. Whiteside A, Cohen J, Strauss M. Reconciling the science and policy divide: The reality of scaling up antiretroviral therapy in South Africa. South Afr J HIV Med 2015;16(1), Art. #355, 5 pages. http:// dx.doi.org/10.4102/sajhivmed.v16i1.355 21. Steyn F, Schneider H, Engelbrecht MC, van Rensburg-Bonthuyzen EJ, Jacobs N, van Rensburg DH. Scaling up access to antiretroviral drugs in a middle-income country: Public sector drug delivery in the Free State, South Africa. AIDS Care 2008;21(1):1-6. http://dx.doi.org/10.1080/09540120903131138 22. Tetteh E. Creating reliable pharmaceutical distribution networks and supply chains in African countries: Implications for access to medicines. Res Social Adm Pharm 2009;5(3):286-297. http:// dx.doi.org/10.1016/j.sapharm.2008.08.001 23. Berhanemeskel E, Beedemariam G, Fenta TG. HIV/AIDS related commodities supply chain management in public health facilities of Addis Ababa, Ethiopia: A cross-sectional survey. J Pharm Policy Pract 2016;9:11. http://dx.doi.org/10.1186/s40545-016-0060-z 24. Quick JD, Boohene NA, Rankin J, Mbwasi RJ. Medicines supply in Africa. BMJ 2005;331(7519):709710. http://dx.doi.org/10.1136/bmj.331.7519.709 25. National Department of Health. National Health Insurance for South Africa: Towards Universal Health Coverage. Pretoria: NDoH, 2015.

Accepted 28 March 2017.

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Enough is not enough: Medical students’ knowledge of early warning signs of childhood cancer J A Geel,1,2 MB ChB, FCPaed (SA), Cert Med Onc (Paed), MMed (Paed); B T Stevenson,1 MB BCh; R B Jennings,3 BA; L E Krook,1 BEngSc (BME), MB BCh; S J Winnan,1 MB BCh; B T Katz,1 MB BCh; T J Fox,1 MB BCh; L Nyati,1,4 MSc Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, South Africa 3 Faculty of Biological Sciences, Wellesley College, Mass., USA 4 Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa 1 2

Corresponding author: J Geel (jennifer.geel@wits.ac.za) Background. The reported incidence of childhood cancer in upper-middle-income South Africa (SA) is much lower than in high-income countries, partly due to under-diagnosis and under-reporting. Documented survival rates are disturbingly low, prompting an analysis of potential factors that may be responsible. Objectives. To determine final-year medical students’ level of knowledge of early warning signs of childhood cancer and whether a correlation existed between test scores and participants’ age, gender and previous exposure to a person with cancer. Methods. A two-part questionnaire based on the Saint Siluan mnemonic, testing both recall and recognition of early warning signs of childhood cancer, was administered. The Mann-Whitney-Wilcoxon test was used to assess differences in continuous and count variables between demographic data, experience and responses, and Fisher’s exact test and Spearman’s rank correlation coefficient were used to determine correlations between demographic data, previous contact with persons with cancer and test scores. A novel equality ratio was calculated to compare the recall and recognition sections and allowed analysis of recall v. recognition. Results. The 84 participants recalled a median of six signs each (interquartile range 4 - 7) and correctly recognised a median of 70% in the recognition section, considered a pass mark. There was no correlation between participants’ age, gender, previous contact with a person with cancer and recognition scores. Students with previous exposure to a person with cancer had higher scores in the recall section, but this did not achieve statistical significance. Students were able to recognise more signs of haematological malignancies than central nervous system (CNS) malignancies. Conclusion. The study demonstrated a marked inconsistency between recall and recognition of signs of childhood cancer, with signs of CNS malignancies being least recognised. However, the majority of students could recognise enough early warning signs to meet the university pass standard. Although this study demonstrated acceptable recognition of early warning signs of childhood cancer at one university, we suggest that long-term recall in medical practitioners is poor, as reflected in the low age-standardised ratios of childhood cancer in SA. We recommend increased ongoing exposure to paediatric oncology in medical school and improved awareness programmes to increase early referrals. S Afr Med J 2017;107(7):585-589. DOI:10.7196/SAMJ.2017.v107i7.12211

Childhood cancer constitutes a leading cause of childhood mortality in high-income countries (HICs).[1] Seemingly paradoxically, 5-year overall survival rates of children with cancer exceed 80%.[2] Unfortunately, despite availability of most of the treatment modalities required to treat childhood cancer, the reported survival rates of South African (SA) children with cancer range between 48%[3] and 52%.[4] The leading causes of under-5 mortality in SA are intestinal infectious diseases, respiratory and cardiac diseases, disease in the neonatal period, influenza and pneumonia, and other neonatal causes,[5] but as SA’s economy has matured from a lower-middleincome country to an upper-middle-income country in the past three decades,[6] it is predicted that diseases more prevalent in HICs will become more important. The age-standardised ratio of childhood cancer is approximately 130 - 160 per million children in HICs. [2] In SA there are approximately 16.2 million children aged <15 years.[7] If the expected incidence rate is applied to the SA population, an annual rate of 900 - 2 500 new cases of paediatric malignancies would be expected. According to the most recent publication from the South African Paediatric Tumour

Registry,[8] ~700 new cases per year were reported. The reported incidence of childhood cancer is therefore much lower than that in HICs, in part due to under-diagnosis and under-reporting of cases.[9] It has been estimated that two-thirds of SA children with cancer do not reach an appropriate specialist centre, and many of the children who present to a paediatric oncology unit do so with advanced disease.[3] Early warning signs of childhood cancer can easily be mistaken for common and less severe illnesses and can therefore be missed. The majority of paediatric malignancies are embryonal in origin, as opposed to the epithelial malignancies seen in adults, and potentially have higher survival rates.[2] Paediatric malignancies are usually the result of DNA mutations occurring at an early stage in life, with environmental and lifestyle risk factors playing little or no role.[10] As they have short latency periods and rapid growth,[1] more emphasis is placed on early detection, as opposed to the emphasis on preventive measures in adults. In order to increase the detection and rapid, appropriate referral of children with cancer, a group of doctors working in the paediatric

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oncology field devised and disseminated the Saint Siluan early warning signs of childhood cancer.[3] This mnemonic encompasses signs and symptoms of >80% of childhood cancers and has been adopted by the International Society of Paediatric Oncology (SIOP) as an effective tool to increase diagnoses and referrals.[11] It has not yet been established in the available literature whether late referrals of children with cancer due to medical delays (i.e. delays associated with misdiagnoses rather than infrastructural or socioeconomic issues) are associated with poor training or suboptimal recall of the signs of childhood cancer, and there is no documented baseline level of knowledge. While there may be numerous other causes of medical delays, this study focused on medical education alone. It was conducted by medical students as part of a compulsory research block.

Objective

In order to plan and evaluate awareness programmes, it is essential to establish baseline knowledge in health professionals. The objective of the current study was to determine the level and depth of knowledge of the early warning signs of childhood cancer among final-year medical students at a single university. Given the high number of undiagnosed childhood cancer patients in the SA setting, a secondary aim in selecting this population was to increase awareness about early warning signs of childhood cancer in future medical practitioners.

Methods

Population and sample size

Final-year medical students were targeted in this survey, as various studies have indicated that delays in diagnosis are frequently associated with medical rather than parental delays.[9] The premise was that medical students completing a long period of intensive study and training and about to embark on internship would be expected to have a safe level of knowledge. The study was conducted midway through the year on the 2014 class of final-year medical students. All respondents who gave consent were included. The sample population reflected a convenience sample of the total number of individuals in the population group.

Data collection

As there are currently no validated questionnaires to determine knowledge of early warning signs of childhood cancer, we used the Saint Siluan mnemonic as a framework to develop a questionnaire, in combination with a questionnaire described in an article from Brazil,[12] a country with economic and social similarities to SA, and used to assess the knowledge of childhood cancer among community health workers. Respondents were also asked to provide demographic data (gender and age), whether they knew anyone (child or adult) with cancer, and whether they had had any exposure to a patient with cancer. Data were collected by means of self-administration of the questionnaire at a non-compulsory class meeting. It has been reported that questionnaires based on recognition rather than recall yield higher scores,[13] so both assessment modalities were incorporated into the questionnaire in this study. Part 1 comprised an unstructured questionnaire in which participants were asked to recall as many signs of childhood cancer as possible. Part 2 consisted of a structured questionnaire in which participants were asked to indicate which signs from a list of 20 were indeed signs of childhood cancer. This section consisted entirely of actual signs of childhood cancer, i.e. there were no misleading questions, and signs were selected to

be representative of the most common paediatric malignancies. The participants were instructed not to turn back to add anything to part 1 once they had turned over to part 2, to make sure that part 1 accurately tested unprompted recall. There was no time limit, and participants returned the questionnaires when they were completed. On completion, they were given an awareness leaflet about early warning signs of childhood cancer, provided by the Childhood Cancer Foundation of South Africa (CHOC). The completed questionnaires were then marked by two student members of the research team, and each marked questionnaire was checked by a paediatric oncologist (JG).

Statistical analysis

In the recall section, participants were required to furnish as many signs of childhood cancer as they could remember. There was therefore no finite score to attain (i.e. no denominator with which to compare the recall answers of the study population). An equality ratio was thus created to assess the consistency between the recall and recognition abilities of the students. The ratio was calculated by the following formula: ‘number of correct recall answers/number of correct recognition answers’ for each student. Participants who did not provide a single correct answer in recall and/or recognition were excluded from the equality ratio (five participants). A score of 1 in the equality ratio was considered ideal, as this hypothetically shows an equivalence between ability to recall a fact unprompted and recognising the same fact when prompted. Continuous and count data (age, recall, recognition and equality ratio) were assessed for normality and presented as medians with interquartile ranges (IQRs). The Mann-Whitney-Wilcoxon test was used to assess differences in continuous and count variables between demographic data, experience and responses. Spearman’s rank correlation was used to assess associations between continuous and count variables. All analyses were performed at the 95% confidence interval using Stata Statistical Software, version 13 (StataCorp, USA). Statistical significance was defined as p<0.05.

Ethics and institutional approval

Permission to conduct the study was obtained from the Dean of the Faculty of Health Sciences and the Human Research Ethics Committee (HREC), University of the Witwatersrand (Wits) (ref. no. M140348).

Results

The questionnaires were completed by 84 students at the noncompulsory class meeting, at which 130 of the 220 students registered were present, representing a response rate of 84/130 (64.6%). Respondents included 62 females, 21 males and one of unspecified gender, with a median age of 24 years (range 22 - 35). Of the students who completed the questionnaire, 51 (60.7%) reported having been involved in the management of a person with cancer, 50 (59.5%) having both known and been involved in the medical management of a person with cancer, and one having neither known nor been involved in the management of a person with cancer. No student reported having only known a person with cancer. The median number of correctly recalled responses was 6 (IQR 4 7). Neither gender nor age was associated with higher scores in the recall section (p=0.390 and p=0.870, respectively). In addition, no correlation was detected between higher recall scores and knowing a person with cancer (p=0.725) or having been involved in the management a patient with cancer (p=0.807). The participants correctly identified 70% of the signs from the list of 20 options; 70.2% of participants could recognise at least

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60% (considered a pass at Wits Medical School) of the listed signs, while 44.1% of participants could correctly identify more than 75% (considered a first-class pass) of the signs (range 0 - 100%) (Fig. 1). No correlation was found between scores achieved and the participant’s gender (p=0.650) or age (p=0.850) in the recognition section. The participants had high scores when asked to identify signs relating to haematological malignancies such as unexplained bleeding, correctly identified by 85.7%, easy bruising (86.9%) and fatigue (85.7%) (Fig. 2). Symptoms such as unexplained fever (81.0%) and loss of weight and appetite (88.9%) were also well recognised. Participants showed poor recognition of neurological signs such as a change in balance (44.1%) and an enlarging head (41.7%), as well as one of the signs of leukaemia, aching joints (48.8%). The relationship between the recall and recognition sections was tested using Spearman’s rank correlation coefficient, and these were determined to be independent of each another (Spearman’s ρ=–0.033, p=0.763). The median equality ratio score for the participants was 0.47 (IQR 0.29 - 0.58), indicating that the majority of the students scored higher in the recognition section than in the recall section.

Frequency, n

20 15 10 5 0 0

100

Recognition, %

Fig. 1. Histogram of participant scores achieved in the recognition section of the test. 100 90 80

Participants, %

70 60 50 40 30 20 10

Loss

of w e

ight

and app etite Easy Une bruis xpla ing ined blee ding Fatig Une ue xpla Palp ined able feve une xpla r in Cha ed lu nge mp in m ilest one s Easy frac ture Whit s e sp ot in eye Hea dac he New squ int Blin dne ss Ach ing bon Bulg es in g ey Cha eba nge ll in b eha viou r Ach ing bac Cha k nge in g ait Ach ing join Cha ts nge in b alan ce Enla rgin g he ad

Signs of childhood cancer

Fig. 2. Percentage of student participants who correctly identified the early warning signs of childhood cancer.

There were negative correlations between test scores and gender, personal experience, clinical experience, and the combination of clinical and personal experience (Fig. 3).

Discussion

This student-initiated study aimed to determine knowledge of early warning signs of childhood cancer in final-year medical students at a single university. Both recall and recognition questions were used to assess knowledge of the early warning signs. As predicted, students attained higher scores in the recognition section than in the recall section. Recognition questions prompt students’ memories, allowing them to recall signs that they may otherwise not have remembered as signs of childhood cancer.[13] Previous clinical experience of a patient with cancer was found to have a statistically significant impact on the equality ratio in the study population, suggesting that clinical experience is associated with an increased equality between recall and recognition of childhood cancer symptoms. The overall median of 0.47 suggests a discrepancy in the recall v. recognition abilities of the students. With the population mean being <1, and given that the mean score in the recognition section was 68.1%, it may be inferred that medical students are trained to recognise signs and symptoms rather than being able to recall them from memory. Signs indicating central nervous system (CNS) malignancies were under-recognised in this study, fewer than half the respondents being able to recognise neurological deficits and an enlarging head as potential signs of childhood cancer (Fig. 2). Certain presenting symptoms are related to diagnostic delays, with CNS tumours having both the longest median delay and the highest risks for physician delay.[1,9,14] As CNS malignancies are the second most common form of childhood cancer in SA,[8] the observation that so many of our students were unaware of their signs is particularly concerning. Longer diagnostic delays in CNS malignancies increase the likelihood that children will develop cognitive and learning difficulties as well as irreversible neurological deficits.[14] In contrast, children who are diagnosed earlier in the disease process tend to have fewer long-term complications.[14] State primary- and secondary-level healthcare facilities may be where the child with cancer first encounters healthcare professionals, including junior doctors, who could detect early warning signs. Without adequate familiarity with these signs, delays in diagnosis are almost inevitable.[12] Early diagnosis enables timely treatment and may prevent unnecessary complications.[14] The importance of educating the healthcare community on early warning signs has been documented over more than two decades.[15] It has been agreed that a wider range of medical professionals should be educated, and that knowledge of early warning signs of childhood cancer should not be limited to paediatric oncologists.[9,16] In SA there is a clear need to increase awareness, given that physician delays tend to be longer than patient delays, and that >50% of patients are initially misdiagnosed.[9] A significantly longer overall delay, including physician delay, has been documented when a child’s presenting symptom is pain,[12] and the current study confirmed that aching joints and bones are poorly recognised, suggesting the possibility that these will be missed in a clinical setting. Poor knowledge of neurological signs should be addressed by placing more emphasis on neurological tumours of childhood, with increased patient exposure in the academic hospitals during undergraduate training.

Study limitations

The survey method, while approximating an undergraduate testing experience and approved by the HREC, was not formally approved

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with cancer in SA should be addressed as a matter of urgency. This study contributes to the small but growing body of data addressing this issue, and should be taken into account when planning awareness campaigns.

B 100

100

Recognition, %

60 40 20

60 40

Conclusion

20 0

0 0

Recall(count)

Male Male

Spearman correlation between recall and recognition: Males: R = Males: R=–0.18, p=0.46 Females: R=–0.003, p=0.98

Female Female

Spearman correlation between- 0.18 recall and recognition: Yes personal experience R=–0.18, p=0.20 No personal experience: R=0.18, p=0.19

D 100

100

Recognition, %

10 Recall (count)

60 40 20 0

Personal experience Personal experience

Clinical experience Clinical experience

No personal experience No personal experience

Spearman correlation between recall and recognition: Clinical experience: R=0.26, p=0.19 Clinical and personal experience: R=–0.16, p=0.28

Recall (count)

Clinical & personal experience Clinical & personal experience

Spearman correlation between recall and recognition: Equality <1: R=0.20, p=0.09 Equality ≥1: R=–0.53, p=0.12

Fig. 3. Negative correlations between gender (A), personal experience (B), clinical experience (C) and the combination of clinical and personal experience (D) and test scores.

as a testing method by an examinations committee and therefore cannot be directly compared with university test scores. The questionnaire was completed in an uncontrolled environment, and not all students were in attendance. Consequently, the study participants could have belonged to a specific subset in the class comprising individuals who were more likely to attend formal academic training sessions and who therefore might be expected to score higher in the questionnaire, and not be a true representation of the class in its entirety. The response rate of 64.6% is considered adequate, but the possibility that the scores were influenced by selection bias cannot be ignored, and the sample size was not as large as was anticipated. The age range of the class was narrow, as was expected, and it was therefore not possible to detect any difference in scores associated with age. The wording of the question: ‘Do you know anyone (child or adult) who has/had cancer’, allowed for ambiguity in its interpretation. The aim was to determine whether the participants had personal knowledge of someone with cancer, but the question allowed for overlap between those who knew someone personally and those who had had clinical contact with a patient with cancer, potentially allowing both groups to answer ‘yes’. The equality ratio devised for this study

is a theoretical concept and has not yet been validated. The survey was conducted in a single SA university and the findings may therefore not be applicable to other settings.

Recommendations

Healthcare workers should be skilled in recognising early warning signs of childhood cancer in order to diagnose and refer patients appropriately and promptly. All healthcare workers who interact with children should be made aware of these warning signs to decrease delays. These professionals include but are not limited to primary healthcare workers, general practitioners, paediatricians, and traditional and complementary practitioners. There may be a need for reassessment of the methods of medical student training regarding childhood cancer. Of necessity, as a result of the growing numbers of students in medical schools nationwide, examinations using the multiple-choice format have assumed greater importance. We postulate that this may have contributed to the skewing of learning towards recognition and away from recall. While it would take studies with far greater scope than this one to detect or confirm an association between learning and teaching methods and early detection rates of childhood cancers, it is recommended that attention be directed to this issue. The unacceptably low survival rate of children

July 2017, Print edition

The low survival rate of children with cancer in SA requires urgent attention and research to determine its many causes. While medical education is not the only factor impacting on this issue, it is an important one and can be addressed in the formal university setting. No correlation was demonstrated between the ability of students in this study to correctly recall answers and knowledge of a person with cancer. Moreover, no association was observed between their ability to recognise signs of cancer and previous clinical experience. Although a score at the level of a university pass was attained by 70% of final-year medical students when asked to recognise early signs of childhood cancer, these students demonstrated a lack of consistency between recall and recognition, with overall reliance on recognition based on analysis of the equality ratio. This novel tool shows potential for the ongoing evaluation of levels of knowledge of such concepts. Participants demonstrated higher levels of awareness of signs relating to haematological cancers than signs of CNS malignancies. Improving survival rates of children with cancer will require a thoughtful, multipronged approach, and increasing awareness at medical school represents the foundation of this undertaking. Despite our respondents achieving the required scores to pass university examinations, we contend that more effort may be required to increase the depth and recall of knowledge. Emphasis should be placed on increasing contact time with patients. Enough is not enough … Acknowledgements. The authors wish to thank Drs S Carrim, Z Dlamini, K Gama, L Matlala, E Milwid, K Naicker, J Omony, N Rasool and C von Bardeleben for their input into the original research project, Ms Adri Ludick of CHOC for information leaflets and ongoing assistance, and Prof. Ben Sartorius for statistical assistance. Author contributions. JAG conceptualised the study, supervised the project and wrote the article. BTS, LEK, SW, BTK and TJF collected and analysed data, wrote the initial report and contributed to the article. RBJ contributed to statistical analysis and co-wrote the manuscript. LN performed statistical analysis and contributed to the article. Funding. None. Conflicts of interest. None.

RESEARCH

1. Dang-Tan T, Franco EL. Diagnosis delays in childhood cancer. Cancer 2007;110(4):703-713. http:// dx.doi.org/10.1002/cncr.22849 2. Kaatsch P. Epidemiology of childhood cancer. Cancer Treat Rev 2010;36(4):277-285. http://dx.doi. org/10.1016/j.ctrv.2010.02.003 3. Poyiadjis S, Wainwright L, Naidu G, et al. The Saint Siluan warning signs of cancer in children: Impact of education in rural South Africa. Pediatr Blood Cancer 2011;56(2):314-316. http://dx.doi. org/10.1002/pbc.22853 4. Stones DK, de Bruin GP, Esterhuizen TM, et al. Childhood cancer survival rates in two South African units. S Afr Med J 2014;105(7):501-504. http://dx.doi.org/10.7196/SAMJ.7882 5. Nannan N, Dorrington RE, Laubscher R, et al. Under-5 Mortality Statistics in South Africa: Shedding Some Light on the Trends and Causes 1997 - 2007. Cape Town: South African Medical Research Council, 2012. http://www.mrc.ac.za/bod/MortalityStatisticsSA.pdf (accessed 1 June 2017). 6. World Bank. Data for upper middle income, South Africa. http://data.worldbank.org/?locations=XTZA (accessed 16 November 2016). 7. Statistics South Africa. Media release, mid-year population estimates 2014. http://www.statssa.gov. za/?p=2990 (accessed 18 June 2015). 8. Stefan DC, Stones DK. The South African Paediatric Tumour Registry – 25 years of activity. S Afr Med J 2012;102(7):605-606. DOI:10.7196/SAMJ.6113 9. Stefan DC, Siemonsma F. Delay and causes of delay in the diagnosis of childhood cancer in Africa. Paediatr Blood Cancer 2010;56(1):80-85. http://dx.doi.org/10.1002/pbc.22714 10. Pizzo PA, Poplack DG. Principles and Practice of Pediatric Oncology. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2012.

This open-access article is distributed under CC-BY-NC 4.0.

11. Perilongo G, Craft A, Jereb B, Wagner H, D’Angio GJ, for the SIOP History Writing Group. The SIOP story: An informal history of the International Society of Pediatric Oncology. Pediatr Blood Cancer 2016;63(S4). http://dx.doi/10.1002/pbc.26170 12. Workman GM, Ribeiro RC, Rai SN, Pedrosa A. Pediatric cancer knowledge: Assessment of knowledge of warning signs and symptoms for pediatric cancer among Brazilian community health workers. J Cancer Educ 2007;22(3):181-185. http://dx.doi.org/10.1007/BF03174334 13. Stubbings S, Robb K, Waller J, et al. Development of a measurement tool to assess public awareness of cancer. Br J Cancer 2009;101(Suppl 2):S13-S17. http://dx.doi/10.1038/sj.bjc.6605385 14. Raney RB, O’Donnell JF, Brooks CM, et al. Pediatric oncologists’ assessment of oncology education in US medical schools: Cancer Education Survey II. J Cancer Educ 1994;9(3):141-144. http://dx.d oi.10.1080/08858199409528295 15. Chantada G, Fandiño A, Manzitti J, et al. Late diagnosis of retinoblastoma in a developing country. Arch Dis Child 1999;80(2):171-174. http://dx.doi.org/10.1136/adc.80.2.171 16. Wilne S, Koller K, Collier J, et al. The diagnosis of brain tumours in children: A guideline to assist healthcare professionals in the assessment of children who may have a brain tumour. Arch Dis Child 2010;95(7):534-539. http://dx.doi.org/10.1136/adc.2009.162057

Accepted 27 February 2017.

National South African HIV prevalence estimates robust despite substantial test non-participation

G Harling,1,2 MA, MPH, ScD; S Moyo,3 MB ChB, MPH, PhD; M E McGovern,4,5 PhD; M Mabaso,3 MSc, PhD; G Marra,6 MSc, PhD; T Bärnighausen,2,7,8 MD, MSc, MSc, ScD; T Rehle,3,9 MD, PhD Research Department of Infection and Population Health, Institute for Global Health, University College London, UK Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA 3 Human Sciences Research Council, Cape Town, South Africa 4 Centre for Health Research at the Management School (CHaRMS), Queen’s University Belfast, UK 5 UKCRC Centre of Excellence for Public Health (Northern Ireland), UK 6 Department of Statistics, University College London, UK 7 Institute of Public Health, University of Heidelberg, Germany 8 Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa 9 Centre for Infectious Disease Epidemiology, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 1 2

Background. South African (SA) national HIV seroprevalence estimates are of crucial policy relevance in the country, and for the worldwide HIV response. However, the most recent nationally representative HIV test survey in 2012 had 22% test non-participation, leaving the potential for substantial bias in current seroprevalence estimates, even after controlling for selection on observed factors. Objective. To re-estimate national HIV prevalence in SA, controlling for bias due to selection on both observed and unobserved factors in the 2012 SA National HIV Prevalence, Incidence and Behaviour Survey. Methods. We jointly estimated regression models for consent to test and HIV status in a Heckman-type bivariate probit framework. As selection variable, we used assigned interviewer identity, a variable known to predict consent but highly unlikely to be associated with interviewees’ HIV status. From these models, we estimated the HIV status of interviewed participants who did not test. Results. Of 26 710 interviewed participants who were invited to test for HIV, 21.3% of females and 24.3% of males declined. Interviewer identity was strongly correlated with consent to test for HIV; declining a test was weakly associated with HIV serostatus. Our HIV prevalence estimates were not significantly different from those using standard methods to control for bias due to selection on observed factors: 15.1% (95% confidence interval (CI) 12.1 - 18.6) v. 14.5% (95% CI 12.8 - 16.3) for 15 - 49-year-old males; 23.3% (95% CI 21.7 - 25.8) v. 23.2% (95% CI 21.3 - 25.1) for 15 - 49-year-old females. Conclusion. The most recent SA HIV prevalence estimates are robust under the strongest available test for selection bias due to missing data. Our findings support the reliability of inferences drawn from such data. S Afr Med J 2017;107(7):590-594. DOI:10.7196/SAMJ.2017.v107i7.11207

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.11207

July 2017, Print edition

These open-access articles are distributed under Creative Commons licence CC-BY-NC 4.0.

RESEARCH

Incidence of chemotherapy-induced neutropenia in HIV-infected and uninfected patients with breast cancer receiving neoadjuvant chemotherapy S Ngidi,1 MB ChB, FC Rad Onc (SA); N Magula,2 BSc, MB ChB, FCP (SA), MSc, PhD; B Sartorius,3 PhD; P Govender,1 MB ChB, FC Rad Onc (SA), MMed; T E Madiba,4 MB ChB, MMed, LLM, PhD, FCS (SA), FASCRS Department of Radiation Oncology, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 2 Department of Internal Medicine, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 3 Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 4 Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 1

Corresponding author: S Ngidi (drsngidi@gmail.com) Background. Chemotherapy-induced neutropenia (CIN) can result in poor tolerance of chemotherapy, leading to dose reductions, delays in therapy schedules, morbidity and mortality. Actively identifying predisposing risk factors before treatment is of paramount importance. We hypothesised that chemotherapy is associated with a greater increase in CIN and its complications in HIV-infected patients than in those who are not infected. Objective. To establish the incidence of CIN in HIV-infected and uninfected patients undergoing chemotherapy. Methods. A retrospective chart review and analysis was conducted in the oncology departments at Inkosi Albert Luthuli Central Hospital and Addington Hospital, Durban, South Africa. The study population consisted of 65 previously untreated women of all ages with stage II - IV breast cancer and known HIV status treated with neoadjuvant chemotherapy from January 2012 to December 2015. Results. HIV-infected patients formed 32.3% of the group, and 95.2% of them were on antiretroviral therapy. The mean age (standard deviation (SD)) of the cohort was 48.5 (13.2) years (40.6 (9.6) years for the HIV-infected group v. 52.0 (13.1) years for the uninfected group; p<0.001). Ninety-five neutropenia episodes were observed (rate 0.85 per 1 year of follow-up time). Following multivariate adjustment, patients with HIV infection were almost two times more likely to develop CIN (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.06Â 2.92; p=0.029. A high baseline absolute neutrophil countÂ (ANC) (HR 0.80, 95% CI 0.68 - 0.95; p=0.005) remained significantly associated with protection against CIN. Conclusions. HIV-infected patients were younger than those who were not infected, and presented at a more locally advanced stage of disease. HIV infection was an independent predictor for CIN. HIV-infected patients had an almost two-fold increased risk of developing CIN and developed neutropenia at a much faster rate. A high baseline white cell count and ANC were protective against CIN. S Afr Med J 2017;107(7):595-601. DOI:10.7196/SAMJ.2017.v107i7.12309

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12309

July 2017, Print edition

RESEARCH

An increase in rates of obstetric haemorrhage in a setting of high HIV seroprevalence E Shabalala, MB ChB; H M Sebitloane, MB ChB, FCOG (SA), MMed, PhD Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: H M Sebitloane (sebitloanem@ukzn.ac.za) Background. Obstetric haemorrhage (OH) is the leading cause of maternal mortality worldwide, although, indirectly, HIV is also a leading cause of maternal mortality in some settings with a high HIV seroprevalence. Objective. To determine the possible association between increasing rates of OH and HIV or its treatment. Methods. We conducted a retrospective chart review of women with OH at King Edward VIII Hospital, Durban, South Africa, over a 3-year period (2009 - 2011), during which the drug regimen for the prevention of mother-to-child transmission was evolving from single-dose nevirapine to antenatal zidovudine combined with intrapartum nevirapine (also referred to as dual therapy), and finally to a combination or highly active antiretroviral therapy (cART or HAART). Cases of OH (including abruptio placentae, placenta praevia, unspecified antepartum haemorrhage (APH), and postpartum haemorrhage (PPH)) were identified from maternity delivery records, and the relevant data extracted. Results. We analysed the records of 448 women diagnosed with OH. Even though the incidence of OH was low, the study found an increasing number of cases during the 3-year period. PPH â&#x20AC;&#x201C; not APH â&#x20AC;&#x201C; was associated with HIV seropositivity (odds ratio 1.84, 95% confidence interval 1.14 - 2.95). cART was not associated with an increased risk of haemorrhage. Conclusion. HIV was associated with a high risk of PPH, and its possible association with HIV treatment needs further research. S Afr Med J 2017;107(7):602-605. DOI:10.7196/SAMJ.2017.v107i7.11166

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.11166

Mid-upper arm circumference: A surrogate for body mass index in pregnant women A Fakier,1 MB ChB, FCOG; G Petro,1,2 MB ChB, FCOG; S Fawcus,3,4 MB ChB, FRCOG, MA New Somerset Hospital, Cape Town, South Africa Metro West, Cape Town, South Africa 3 Mowbray Maternity Hospital, Cape Town, South Africa 4 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, South Africa 1 2

Corresponding author: A Fakier (ahminahf@gmail.com) Background. Nutrition in pregnancy has implications for both mother and fetus, hence the importance of an accurate assessment at the booking visit during antenatal care. The body mass index (BMI, kg/m2) is currently the gold standard for measuring body fatness. However, pregnancy-associated weight gain and oedema, as well as late booking in our population setting, cause concern about the reliability of using the BMI to assess body fat or nutritional status in pregnancy. The mid-upper arm circumference (MUAC) has been used for many decades to assess malnutrition in children aged <5 years. Several studies have also shown a strong correlation between MUAC and BMI in both pregnant and non-pregnant adult populations. Objective. To assess the correlation between the MUAC and BMI in pregnant women booking for antenatal care in the Metro West area of Cape Town, South Africa. Methods. We conducted a cross-sectional study of women booking at four midwife obstetric units. Anthropometric measurements (height, weight and MUAC) were carried out on pregnant women at their first antenatal booking visit.

July 2017, Print edition

RESEARCH

Results. The results showed a strong correlation between MUAC and BMI in pregnant women up to 30 weeks’ gestation. The correlation was calculated at 0.92 for the entire group. The MUAC cut-offs for obesity (BMI >30) and malnutrition (BMI <18.5) were calculated as 30.57 cm and 22.8 cm, respectively. Conclusion. MUAC correlates strongly with BMI in pregnancy up to a gestation of 30 weeks in women attending Metro West maternity services. In low-resource settings, the simpler MUAC measurement could reliably be substituted for BMI to assess nutritional status. S Afr Med J 2017;107(7):606-610. DOI:10.7196/SAMJ.2017.v107i7.12255

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12255

Management of failed spinal anaesthesia for caesarean section G W Jones,1 MB BCh, DA (UK), FRCA (UK), MBA, FCA (SA); R A Samuel,2 MB ChB, DA (SA), FCA (SA), MMed; B M Biccard,3 MB ChB, FCA (SA), FFARCSI, MMedSci, PhD Department of Anaesthesia, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Private Practice, Durban, South Africa 3 Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, Groote Schuur Hospital and University of Cape Town, South Africa 1 2

Corresponding author: G W Jones (gavin@jonesmail.co.za)

Background. Failed spinal anaesthesia for caesarean section (CS) may be partial or complete and the subsequent discomfort is the most commonly cited cause of litigation in obstetric anaesthesia. Objectives. To determine if there is a standardised approach to: (i) testing the level of block of spinal anaesthesia; and (ii) the management of failed spinal anaesthesia for CS. Methods. A structured questionnaire to ascertain the current practice of testing the level of block and management of three different scenarios of failed spinal anaesthesia was distributed to 51 government hospitals in KwaZulu-Natal, South Africa (SA). All obstetric anaesthetic service providers, ranging from interns to specialist anaesthetists, were invited to complete the questionnaire. Results. A total of 375 responses were received from 42 of the 51 hospitals surveyed. Specialist anaesthetists managed failure of spinal anaesthesia significantly differently than other anaesthetic service providers. Specialists were more likely to convert to a general anaesthetic (GA), while others were more likely to repeat spinal anaesthesia or administer intravenous ketamine, midazolam and opioids. Only 212 respondents (56%) tested the level of block and there was no difference between the groups with regard to the method of assessment of height (p=0.15). Nonspecialists, however, accepted a significantly lower level of block, using pinprick, than specialists (p=0.027), which could lead to a higher failure rate. More than one-third of non-specialists did not consider themselves competent to perform a GA and >90% of respondents agreed that a ‘failed’ spinal algorithm would be useful. Conclusion. There is a need for standardised assessment of the adequacy of spinal anaesthesia for CS in SA, as well as a failed spinal algorithm. S Afr Med J 2017;107(7):611-614. DOI:10.7196/SAMJ.2017.v107i7.12056

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12056

July 2017, Print edition

RESEARCH

Interprofessional communication in organ transplantation in Gauteng Province, South Africa H R Etheredge,1 PhD; C Penn,2 PhD; J Watermeyer,2 PhD 1 2

Wits Donald Gordon Medical Centre, Johannesburg, South Africa Health Communication Research Unit, School of Human and Community Development, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: H R Etheredge (harriet.etheredge@mediclinic.co.za) Background. Communication is essential to the transplant process, but it is challenging in South Africa (SA) because of the complexity of the country and the health system, the nature of transplantation as a technical procedure with inherent psychological considerations, and the large number of professionals involved. Transplant communication has not been explored in SA, and this study was the first to use health communication methods to generate empirical evidence relating to it. Objective. To explore communication in transplant settings in Gauteng Province, SA. Methods. Qualitative methods were used to collect data across six hospitals and transplant centres in Gauteng. State and private institutions were equally represented. Health professionals and transplant co-ordinators participated. Thematic analysis of data was undertaken. Results. Facilitators of interprofessional transplant communication included appreciation of its importance to good practice and cohesive individual transplant teams. Barriers to interprofessional communication were observed when individual teams had to come together in a multi-team, interdisciplinary environment, when interchange became aggressive, and when information was not passed on to other health professionals timeously. These barriers had implications for continuity of care and ethics, which could lead to moral distress. Conclusion. Transplantation in Gauteng is characterised by aspects of good teamwork, and the importance of effective communication is acknowledged. Transplantation also faces some challenges in terms of interprofessional communication. Recommendations for mitigating some of the gaps include integrating a health communication specialist into the transplant process, â&#x20AC;&#x2DC;knotworkingâ&#x20AC;&#x2122;, the use of apology, and an advance warning text-message system for transplant professionals. S Afr Med J 2017;107(7):615-620. DOI:10.7196/SAMJ.2017.v107i7.12355

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12355

An audit of traumatic brain injury (TBI) in a busy developing-world trauma service exposes a significant deficit in resources available to manage severe TBI E Jerome,1 MB ChB, MRCS (Edin); G L Laing,1 FCS (SA), Cert Trauma Care, PhD; J L Bruce,1 FCS (SA); B Sartorius,2 BSc, BSc Hons, MSc, PhD; P Brysiewicz,3 BSocSc, BA, MCur, PhD; D L Clarke,1,4 FCS (SA), MMedSci, MBA, MPhil, PhD Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, University of KwaZulu-Natal, Pietermaritzburg, South Africa Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa 3 Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa 4 Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 1 2

Corresponding author: P Brysiewicz (brysiewiczp@ukzn.ac.za) Background. Traumatic brain injury (TBI) affects large numbers of patients, both adults and children, and significant resources are needed to manage it. Objective. To determine the burden of TBI and the adequacy of available resources to manage in the Pietermaritzburg Metropolitan Trauma Service (PMTS).

July 2017, Print edition

RESEARCH

Methods. All patients with a TBI were identified from the hybrid electronic medical registry at Grey’s and Edendale hospitals in Pietermaritzburg (PMB), KwaZulu-Natal, South Africa. Patients were classified according to severity of head injury and age. We defined mild TBI as Glasgow coma scale (GCS) 13 - 15, moderate as GCS 9 - 12, and severe as GCS ≤8, in accordance with international standards. We divided the cohort according to ages 0 - 5 years, 6 - 10 years, >10 - 17 years and adults (>17 years). Results. From January 2012 to December 2014, 3 301 patients were treated for TBI in PMB. The mean age was 27.4 (standard deviation 14.4) years. There were 2 632 males and 564 females. There were 2 540 mild, 326 moderate, and 329 severe TBI admissions during the period under review. A total of 139 (4.2%) patients died. A total of 242 (7.3%) patients were admitted to the intensive care unit (ICU), of whom 137 (57.0%) had a GCS of ≤9. Only 27.0% of patients with a GCS of ≤9 were admitted to the ICU. Conclusion. There is a significant burden of TBI managed by the PMTS. Critical care resources available to manage patients with TBI are inadequate. S Afr Med J 2017;107(7):621-625. DOI:10.7196/SAMJ.2017.v107i7.10562

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.10562

The burden of gunshot injuries on orthopaedic healthcare resources in South Africa C Martin,1 MD, MSc; G Thiart,2 MB ChB; G McCollum,2 MB ChB, MMed, FC Ortho; S Roche,2 MB ChB, MMed, FC Ortho; S Maqungo,2 MB ChB, MMed, FC Ortho 1 2

Department of Orthopaedics, School of Medicine, University of Texas Health San Antonio, USA Department of Orthopaedic Surgery, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: C Martin (casewmartin@gmail.com) Background. Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. Objective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. Methods. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. Results. A total of 111 patients with an average age of 28 years (range 13 - 74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 - 7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. Conclusion. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives. S Afr Med J 2017;107(7):626-630. DOI:10.7196/SAMJ.2017.v107i7.12257

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12257

July 2017, Print edition

RESEARCH

A finger or not? Prostate examinations by non-urologists at a South African academic institution K Spencer, MB BCh Department of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: K Spencer (doctorkspencer@gmail.com) Background. According to the South African (SA) National Cancer Registry 2009, prostate cancer is the most commonly diagnosed solidorgan cancer in SA men: the incidence increases at ~3% every year, with 1/26 men developing prostate cancer in their lifetime and five men dying every day. Screening for prostate cancer by performing a digital rectal examination (DRE) adds to the sensitivity and specificity of serum prostate-specific antigen (PSA) testing and is an important component of the assessment for the early detection of prostate cancer. Objectives. To ascertain whether doctors who are not in the field of urology perform DREs and PSA testing to screen for prostate cancer, where indicated, and to determine the reason, if any, why doctors do not perform prostate examinations. Methods. Doctors (including specialists and primary care practitioners) who consulted adult male patients in the emergency departments and polyclinics of three academic hospitals were included in the sample and asked to complete an anonymous questionnaire. Doctors with specialist urological training were excluded from the sample. The questionnaire included the following aspects: gender, year of graduation and university, current position, knowledge of PSA screening and DRE, whether these were being performed, and reasons for nonperformance. Results. The response rate was 303/350 participants. Fifty-nine percent of the respondents were female. The median duration of experience was 5 years. The mean (standard deviation) knowledge score with regard to screening was 56.1% (20). The PSA test alone was most frequently done (35%), followed by asking the patient about urinary tract symptoms (28%). In contrast, DRE of the prostate, alone or combined with a PSA test, was performed less frequently (13.2% and 10.6%, respectively). Some of the most common reasons for not performing a DRE included: ‘It’s more convenient to do a PSA test’; ‘Urologists will examine the prostate anyway’; ‘No privacy in the emergency department/admission ward’; ‘Prostate exam is not relevant to my practice’; ‘There is not enough time’; and ‘The practitioner forgets’. Doctors with >7 years of working experience are the least likely to do a DRE. Conclusion. Performance rates of DRE and PSA testing by doctors who are not urologists are very low, which may have significant clinical implications. It is recommended that SA prostate cancer screening guidelines are necessary to change practice with regard to this condition. S Afr Med J 2017;107(7):631-635. DOI:10.7196/SAMJ.2017.v107i7.12208

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12208

Characteristics and correlates of alcohol consumption among adult chronic care patients in North West Province, South Africa A Bhana,1,2 MA, PhD; S D Rathod,3 MSc, PhD; O Selohilwe,2 MA; T Kathree,2 MA; I Petersen,2 MSc, PhD Health Systems Research Unit, South African Medical Research Council, Durban, South Africa Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa 3 Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK 1 2

Corresponding author: A Bhana (arvin.bhana@mrc.ac.za) Background. Alcohol consumption patterns in South Africa (SA) tend to be characterised by risky patterns of drinking. Taken together with the large burden of disease associated with HIV and tuberculosis (TB), heavy alcohol consumption patterns with these chronic conditions has the potential to compromise the efficacy of treatment efforts among such patients.

July 2017, Print edition

RESEARCH

Objective. To explore the characteristics, correlates and diagnoses of alcohol use disorders among chronic care patients in SA. Method. A cross-sectional survey was conducted in three public health clinic facilities in the North West Province of SA. A total of 1 322 patients were recruited from non-emergency waiting areas. Results. Proportions of patients with abstinence, hazardous, harmful and dependent consumption were determined using logistic regression. Of the patients screened, nearly half (45%) drank alcohol and, of these, 10% were classified as hazardous drinkers, 1.7% as harmful drinkers, and 1.6% as dependent drinkers (overall 3% alcohol use disorder). Abstinence proportions were 60% and 38% among women and men, respectively. Alcohol Use Disorders Identification Test scores for men were 63% higher than for women. The lowest patient abstinence proportion (47%) and highest dependent drinking (10%) was for TB. The highest abstinence proportion was for diabetes (65%), and the highest hazardous and harmful drinking was among TB (14%) and HIV (7%) patients. Conclusions. The high levels of risky drinking among chronic care patients, particularly among patients receiving treatment for HIV and TB, are concerning. Instituting appropriate screening measures and referral to treatment would be an important first step in mitigating the effects of risky alcohol use among chronic care patients. S Afr Med J 2017;107(7):636-642. DOI:10.7196/SAMJ.2017.v107i7.12131

Full article available online at http://dx.doi.org/10.7196/SAMJ.2017.v107i7.12131

July 2017, Print edition

CAREERS & CLASSIFIEDS Ladine Van Heerden Tel: 012 481 2121 | E-mail: ladinev@hmpg.co.za Makhadzi Mulaudzi Tel: 012 481 2156 | E-mail: makhadzim@hmpg.co.za We accept credit card payments - Visa or MasterCard.

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The purpose of the post is to oversee the organisation’s data management processes, with an emphasis on efficiency and automation, and to critically assess and redefine analytics and reporting for the organisation. This includes reporting on progress against targets, analysis that informs strategic decision-making and monitoring and evaluation (M&E). Minimum requirements Higher Degree in Data Management, Statistics, Public Health, Social Sciences, Health Information Sciences or other relevant degree Diploma or related qualification in Project Management Must have more than 5 years’ working experience in a sector with strong information management Must have been the lead on research publications Valid code 8 driver’s licence and own transport Clear criminal record Key performance areas Data and knowledge management Designs new M&E activities and refines existing ones to meet changing organisation’s priorities, as new funding and activities are added to the THCA portfolio, including but not limited to PEPFAR/CDC, Global Fund, and DOH Responsible for the development of the data capture system, moving it from a paper-based system to an electronicbased system Collects, validates, analyses, interprets, and summarises data collected from the various programmes Drives the development plan for THCA strategic information Identifies opportunities for research based on current data Creates a central repository for all SOPs and implements a document- and version-control system Operational support Supports the programme managers with programme-specific reporting, targets, indicators, and other relevant tools Supports, mentors and capacitates other THCA staff to develop a research portfolio in support of the following strategic activities: health system strengthening, HIV/TB/STI prevention, improved linkage/cascade into treatment care and support, and operations/implementation science. Provides technical assistance on study/research design and data analysis for THCA programmes Operational research and reporting Oversees the compilation and submission of reports on the progress and achievements as per due dates for programme-specific and/or funder requirements Ensures that finalised reports are entered into a central database, prepares presentations and co-ordinates the presentation of findings to the rest of the management team and subcontractors Continuous quality improvement Identifies opportunity for improvement Works with programme managers and subcontractors to ensure implementation of agreed recommendations and processes Ensures all recommendations are documented and SOPs updated Leadership Leads, plans, co-ordinates and implements the development of research protocols, studies, demonstration projects and formative assessments (clinical, operational and implementation based) Manages all M&E-related projects Knowledge, skills and competencies Excellent visual design sense regarding clear and accurate data presentation Demonstrates ability to deal with large volumes of data, with high levels of accuracy and speed Advanced computer literacy. To perform this job successfully, an individual should have knowledge of electronic databases; Microsoft Excel, Word and PowerPoint; experience with statistical software (STATA, SPSS, SAS or EpiInfo); and knowledge of ETR, TIER.net and DHIS will be advantageous Ability to travel regularly within South Africa To apply: Register on www.tbhivcare.org Closing date: 30 June 2017 Only online applications will be accepted. Preference will be given to suitably qualified applicants who are members of the designated groups in line with the Employment Equity Plan and Targets of TB/HIV Care Association. We also encourage people with disabilities to apply. In the event that you have not heard from us a month after the closing date, please consider your application as unsuccessful. TB/HIV Care Association reserves the right to amend and/or withdraw adverts at any time without notification.

Change lives. Including your own.

Experience something different. Make a difference. CALLING ALL HEALTHCARE PROFESSIONALS: volunteer your skills and experience the beauty and lifestyle of the African bush. The under-resourced rural areas of Mpumalanga and Limpopo desperately need quality, primary and specialist healthcare. The Tshemba Foundation is inviting medical professionals to volunteer their skills and services and to make a difference in the South African rural healthcare landscape.

In return, our volunteers will receive five star accommodation in an individual luxury chalet within a protected and secure environment on a private residential game reserve. You will have the opportunity to explore the surrounding area over weekends. On the fringe of the Kruger National Park and numerous game reserves, Tshemba provides a springboard for various forms of game viewing in Big Five Country and for exploring the extraordinary beauty of the Blyde River Canyon and other local places of interest. We can also arrange a host of adventure activities, including river rafting, hiking, mountain biking, horse riding, and aerial cable trails. There are 7 full-time doctors treating patients in the OPD and 400 bed local rural hospital. The patient load and inadequate Primary Health Clinic service in the surrounding rural area without doctor support adds a further strain on the hospital. Hence, the work of the volunteer professional will be rigorous and challenging, but at the same time hugely rewarding. In addition to treating patients, the volunteer will be encouraged to teach and to transfer skills to the local medical workers. The disciplines in critical supply include anaesthetics, gynacology and obstetrics, orthopaedics, paediatrics, medicine, primary care and surgery, but any and all professional healthcare expertise is welcomed.

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The Tshemba Foundation welcomes both local and international doctors. Several young medical professionals have gained an impressive breadth and depth of experience by volunteering with us. And we have also welcomed retiring doctors and doctors taking a sabbatical break, and everyone in between. Choose a volunteering period that suits you: join us for just a couple of weeks, or stay for an extended period. Preference will be given to volunteers who stay for longer than two months, but we are happy to accommodate your schedule. The Tshemba Foundation will ensure that all international volunteer medical professionals are fully licensed to practise by the HPCSA.

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CPD

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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 The evolution of research participant protections in South Africa (SA) 1. The legislative basis for scientific research in SA was first promulgated in 1945. 2. SA’s Constitution includes research and experimentation in its Bill of Rights. Enough is not enough: Medical students’ knowledge of early warning signs of childhood cancer 3. Five-year overall survival rates of children with cancer exceed 80%. 4. Early warning signs of childhood cancer can easily be mistaken for common and less severe illnesses and can therefore be missed. Incidence of chemotherapy-induced neutropenia in HIV-infected and uninfected patients with breast cancer receiving neoadjuvant chemotherapy 5. According to the SA National Cancer Registry in 2014, breast cancer accounted for 20.64% of all cancers and ranked second as the cause of cancer deaths in females. 6. Chemotherapy-induced neutropenia (CIN) is one of the most serious haematological toxicities caused by chemotherapy. Mid-upper arm circumference (MUAC): A surrogate for body mass index (BMI) in pregnant women 7. The MUAC has been used for many decades to assess malnutrition in children aged <5 years. 8. Several studies have shown a strong correlation between MUAC and BMI in the adult population.

CME Acute high-altitude illness 11. High altitude is defined as greater than 1 500 m above sea level. 12. Altitude-related illness starts to manifest at altitudes between 1 500 m and 3 500 m. 13. Onset of altitude-related illness is most common after rapid ascent to above 3 500 m. Update on drowning 14. The terms wet, dry or near drowning are still commonly used. 15. Africa has the highest rate of drowning in the world. 16. Seizure disorders and prolonged QT syndrome should be sought in preventive screening of children considered at risk of drowning. 17. A chest X-ray has no value in the initial evaluation of a drowning patient, unless otherwise indicated. Wilderness cold-exposure injuries: An African perspective 18. Cold injury can only ever occur when the temperature is around freezing point. 19. The definition of hypothermia is a core temperature of <35°C. 20. Even a simple plastic refuse bag can be used to prevent further heat loss in suspected hypothermia in the field.

Characteristics and correlates of alcohol consumption among adult chronic care patients in North West Province, SA 9. SA has high rates of alcohol abstinence. 10. SA records an average level of alcohol consumption of 27.1 litres per annum, while the WHO Africa region recorded an average of 6.0 litres per annum.

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

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July 2017, Print edition

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