SAMJ Vol 107, No 11 (2017) by HMPG

NOVEMBER 2017

PRINT EDITION

CME Contraceptive implants (part 2) IN PRACTICE Kaposiâ&#x20AC;&#x2122;s sarcoma: Long-term outcome in the HAART era Protecting personal information: Implications of the POPI act REVIEW Nystagmus in patients with traumatic brain injury RESEARCH Sensory integration intervention and the development of the premature infant Extraspinal osteoarticular multidrugresistant TB in children Use of healthcare services at truck stops by sex workers The PAWPER XL-MAC system for estimating body weight in critically ill children

For first-line treatment in bleeding oesophageal varices 1

NEW

At the ready to save lives References: 1. Ioannou GN, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage (Review). Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002147. DOI:10.1002/14651858.CD002147. 2. Levacher S, Letoumelin P, Pateron D, et al. Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients. Lancet 1995; 346: 865-868. 3. Söderlund C, Magnusson I, Törngren S, Lundell L. Terlipressin (triglycyl-lysine vasopressin) controls acute bleeding oesophageal varices. Scand J Gastroenterol 1990; 25: 622-630. 4. Feu F, D’Amico G, Bosch J. The acute bleeding episode: advances in drug therapy. In: Arroyo V, Bosch J, Rodés J (eds). Treatments in Hepatology. Masson, Barcelona 1995: 9-22.

S4 GLYPRESSIN® 0,1 mg/ml (Solution for Injection). One ampoule of 8,5 ml solution contains 1 mg terlipressin acetate. Reg. No.: 43/21.13/0829. NAME AND BUSINESS ADDRESS OF THE HOLDER OF THE CERTIFICATE OF REGISTRATION: FERRING (Pty) Ltd. Route 21 Corporate Park, 6 Regency Drive, Irene Ext 30. Pretoria, South Africa. Tel: +27 12 345 6358/9 Fax: +27 12 345 1156. www.ferring.co.za. For full prescribing information refer to the package insert approved by the medicines regulatory authority. 2017/032

Ready mixed, ready to go...

GLYPRESSIN terlipressin Solution acetate

2-4

NOVEMBER 2017 PRINT EDITION

FROM THE EDITOR 4

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

Promoting obesity B Farham

EDITORS EMERITUS Daniel J Ncayiyana, MD (Groningen), FACOG, MD (Hon), FCM (Hon) JP de V van Niekerk, MD, FRCR

EDITOR’S CHOICE CORRESPONDENCE

An approach to anaemia diagnosis – concerns in primary care N Alli, J Vaughan, M Patel

HIV-positive patients in the intensive care unit A Parker, S Lahri, J J Taljaard, C F N Koegelenberg

HMPG

10 End-of-life care and organ and tissue donation in South Africa – it’s time for a national policy to lead the way N Allorto, R Moore, E Andrews, R Martinez, W A Smith, V Medapati, S L Wall, A D Rogers, H Rode

IZINDABA 14

OBITUARY Harold James Mons Duncan R Wise

ARTICLES Lessons learnt from the introduction of the contraceptive implant in South Africa M Pleaner, C Morroni, J Smit, N Lince-Deroche, M F Chersich, S Mullick, D Pillay, M Makua, H Rees

IN PRACTICE

MANAGING EDITORS Claudia Naidu Naadia van der Bergh

PRODUCTION MANAGER Emma Jane Couzens

25 Strengthening implant provision and acceptance in South Africa with the ‘Any woman, any place, any time’ approach: An essential step towards reducing unintended pregnancies H Rees, Y Pillay, S Mullick, M F Chersich

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

TECHNICAL EDITORS Emma Buchanan Kirsten Morreira Paula van der Bijl

30 days in medicine B Farham

CONTINUING MEDICAL EDUCATION 18

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

ISSUES IN MEDICINE The African Hospitalist Fellowship A D Daniels, H Buys, R Dunkley, J M Wilmshurst HEALTHCARE DELIVERY Provision of acute and elective general surgical care at a tertiary facility in the era of subspecialisation J H Klopper, S Rayamajhi, J J Venter, D J de Villiers, N Almgla, J C Kloppers

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 JOURNAL ADVERTISING Reneé Hinze Ladine van Heerden Makhadzi Mulaudzi Charmalin Comalie ONLINE SUPPORT Gertrude Fani FINANCE Tshepiso Mokoena

39 Kaposi’s sarcoma: Good outcome with doxorubicin, bleomycin and vincristine sulphate (ABV) chemotherapy and highly active antiretroviral therapy P B Hesseling, E Katayi, P Wharin, R Bardin, F Kouya, D Palmer, M Glenn, M Kruger

HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Mrs H Kikaya, Prof. E L Mazwai, Dr M Mbokota, Dr G Wolvaardt

MEDICINE AND THE LAW 41 Protecting personal information: Implications of the Protection of Personal Information (POPI) Act for healthcare professionals M Buys

ISSN 0256-9574

REVIEW 44

Investigating nystagmus in patients with traumatic brain injury: A systematic review (1996 - 2016) H de Clercq, A Naudé, J Bornman

RESEARCH 52 Beyond clinical trials: Cross-sectional associations of combination antiretroviral therapy with reports of multiple symptoms and non-adherence among adolescents in South Africa* H P M Natukunda, L D Cluver, E Toska, V Musiime, A R Yakubovich 53

Sensory integration intervention and the development of the premature infant: A controlled trial* E Lecuona, A van Jaarsveld, J Raubenheimer, R van Heerden

November 2017, Print edition

SAMA website: www.samedical.org Journal website: www.samj.org.za

Extraspinal osteoarticular multidrug-resistant tuberculosis in children: A case series* G B Firth, J Lescheid, M Camacho, M Esteves, N Beylis, M J Groome, S A Madhi

Impact of the learning environment on career intentions of paediatric interns* K L Naidoo, J M van Wyk, M Adhikari

Access to and utilisation of healthcare services by sex workers at truck-stop clinics in South Africa: A case study* S C Fobosi, S T Lalla-Edward, S Ncube, F Buthelezi, P Matthew, A Kadyakapita, M Slabbert, C A Hankins, W D F Venter, G B Gomez

Vulvar cancer is not a disease of the elderly: Treatment and outcome at a tertiary referral centre in South Africa* J L Butt, M H Botha Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in South Africa* T S Maswime, E Buchmann

Cost awareness among healthcare professionals at a South African hospital: A cross-sectional survey* G D Nethathe, S Tshukutsoane, K J Denny

Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XL-MAC system* M Wells, L N Goldstein, A Bentley

Endoscopy services in KwaZulu-Natal Province, South Africa, are insuﬃcient for the burden of disease: Is patient care compromised?* E Loots, D L Clarke, K Newton, C J Mulder

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. HEAD OFFICE Health and Medical Publishing Group (Pty) Ltd Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext. 3, Pretoria, 0181 Tel. 012 481 2069 Email: dianes@hmpg.co.za EDITORIAL OFFICE Suite 11, Lonsdale Building, Lonsdale Way, Pinelands, 7405 Tel. 021 532 1281 | Cell. 072 635 9825 Email: publishing@hmpg.co.za

*Abstract only, full article available online. CAREERS AND CLASSIFIEDS CPD QUESTIONS

Please submit all letters and articles for publication online at http://www.editorialmanager.com/samj © Copyright: Health and Medical Publishing Group (Pty) Ltd, a subsidiary of the South African Medical Association Use of editorial material is subject to the Creative Commons Attribution – Non-commercial Works Licence. https://creativecommons.org/licenses/bync/4.0 Printed by TANDYM PRINT

NOVEMBER 2017

Background photo: A 17-year-old woman with MDR-TB receives treatment at a clinic in Gugulethu, Cape Town | Damien Schumann Box photos: Infant sensory integration – tactile play | Elise Lecuona; Knee flexion contracture and scarred sinuses in a patient with extraspinal osteoarticular multidrug-resistant tuberculosis | Firth et al.; Nurse at the door of a truck-stop clinic | Oupa Nkosi

November 2017, Print edition

PRINT EDITION

CME Contraceptive implants (part 2) IN PRACTICE Kaposi’s sarcoma: Long-term outcome in the HAART era Protecting personal information: Implications of the POPI act REVIEW Nystagmus in patients with traumatic brain injury RESEARCH Sensory integration intervention and the development of the premature infant Extraspinal osteoarticular multidrugresistant TB in children Use of healthcare services at truck stops by sex workers The PAWPER XL-MAC system for estimating body weight in critically ill children

MORE THAN DEFENCE

Make the right choice with your professional protection You need an organisation you can trust. We have a long-term commitment to support doctors in South Africa throughout their career, not a short-term requirement to generate profits.

MEDICAL PROTECTION. MORE THAN DEFENCE.

medicalprotection.org/rightchoice

MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. MPS® and Medical Protection® are registered trademarks. mpany. Dental Protection® is a registered trademark of MPS.

6525 MP Setting the Record Straight (Medical Insider A4).indd 1

6525:07/17

The Medical Protection Society Limited (“MPS”) is a company limited by guarantee registered in England with company number 36142 at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG.

11/10/2017 14:43

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

FROM THE EDITOR

Promoting obesity Recently I paid my annual visit to the cinema, to see the new ‘Blade Runner’ on the big screen (I usually prefer a DVD and the comfort of my own home). Before I went, my mother remarked that I must be sure to get myself one of the enormous boxes of popcorn and huge cups of sweetened fizzy drinks that she had seen on one of her rare trips to the cinema last year. Sure enough – while my husband and I waited to get into the show – we saw countless people, children and adults alike, with boxes of popcorn ranging from what to me looked like large to gigantic, but are probably marketed as small to extra-large, and 750 mL cartons of drinks. And with few exceptions the people consuming this junk food were extra-large themselves, including the children. Earlier that day I had happened to be standing in line in Clicks, and noticed that not only did they have the usual assortment of sweets, crisps and fizzy drinks for sale in the pay-point aisles, but they were promoting a ‘meal deal’, which was made up of a packet of crisps, a sweet and a drink – the cheapest being free. Even more remarkable, one of the most utilised medical aid companies in the country offers popcorn and sweetened, fizzy drinks at a local cinema chain as ‘rewards’ for hitting exercise point targets each week! It is no wonder that a recent report in The Lancet shows that a staggering 30% of the world’s population are obese or overweight. At the same time, this week’s BMJ carries a story showing that in the UK spending on junk food advertising is nearly 30 times what government spends on promoting healthy eating.[1] The analysis used data from The Grocer magazine’s top 100 list of advertising spending on fast-moving consumer brands, which identifies brands commonly associated with crisps, sweets and sugary drinks. The analysis showed that companies producing the top 18 UK brands spent more than GBP143 million (USD190 million) on advertising their products last year. This was about 27.5 times the GBP5.2 million annual spending by the UK government’s flagship healthy eating campaign, run by Public Health England. On top of this, the UK’s National Health Service is spending around GBP38 million a year on weight-loss surgery and about GBP5.1 billion a year on treating obesity-related conditions. Locally, South Africa (SA) records the highest obesity rates on the continent, with almost 70% of women either overweight or obese according to the latest South African Demographic and Health Survey.[2] Our local Advertising Code of Practice was amended in 2008 to limit the marketing of unhealthy foods to children aged

under 12. But a National Department of Health policy to increase this to all school-age children has been stalled for several years. And there is plenty of evidence to suggest that junk foods are cheaper than healthy alternatives. A recent article in the Daily Maverick quotes Prof. Vishwas Satgar, chair of the board of the Co-operative Policy Alternative Centre (COPAC), as saying that people sometimes eat junk food out of necessity, as it is cheap (and easily available).[3] However, people and organisations like COPAC, who are advocating changes in food policy and trying to promote accessible, locally produced, fresh, nutritious and culturally appropriate food, are up against the food industry giants. Junk food advertising follows that of tobacco (now banned in SA) and alcohol (the advertising of which probably should be banned) in that it plays on people’s social aspirations, promoting drinking Coca Cola, for example, as being ‘cool’. In sub-Saharan Africa in 2016 alone, Coca Cola spent over ZAR518 million on advertising, according to Nielsen.[4] Various local public health experts say that measures such as the proposed tax on sugary drinks and any future tax on unhealthy foods are a start, but educating people on how sugary and processed foods affect their health is also important. We also need to look at food production and distribution, which have a major effect on how people eat. We cannot expect the food industry to regulate itself. We know that all too well from the tobacco and alcohol industry. The food giants are just as dangerous to people’s health. Bridget Farham Editor ugqirha@iafrica.com 1. O’Dowd A. Spending on junk food advertising is nearly 30 times what government spends on promoting healthy eating. BMJ 2017;359:j4677. https://doi.org/10.1136/bmj.j4677 2. South African Demographic and Health Survey 2016. Key Indicator Report. http://www.statssa.gov.za/ publications/Report%2003-00-09/Report%2003-00-092016.pdf (accessed 16 October 2017). 3. Green A. Health-e News: ‘Ban junk food adverts’. Daily Maverick 2017. https://www.dailymaverick. co.za/article/2017-09-26-health-e-news-ban-junk-food-adverts/#.WeR-WkyB3QY (accessed 16 Octo ber 2017). 4. Nielsen Sub-Saharan Africa. Africa’s Prospects. 2017. http://www.nielsen.com/ssa/en/insights/ reports/2017/africa-prospects-edition-4.html (accessed 16 October 2017).

S Afr Med J 2017;107(11):927. DOI:10.7196/SAMJ.2017.v107i11.12931

November 2017, Print edition

MED-E-MASS

HAS THE EXPERIENCE AND RESOURCES TO GIVE YOUR PRACTICE THE EDGE IT NEEDS Our family of technologically advanced products and services provides you with the best management tools to suit the needs of your practice by offering: PRACTICE MANAGEMENT • • • • • • • • • • •

Patient account management Billing management Automated transactions Financial reporting with graphs Debit and credit card facilities at very competitive rates Stock management Payment plans SMS and email enabled Remote management/synchronisation Microsoft Word and Excel integration Code compatibility (e.g. ICD-10, Nappi, CPT, NHRPL)

PATIENT MANAGEMENT • • • • • • • • • • • •

Visit our website at www.medemass.com or phone 0860 98 00 98 for more information.

Clinical notes Pathology results Tariff services e-Scripting Dispensing Integrated electronic claiming Appointment diary Customisable clinical templates Referrals Patient alerts (allergies and conditions) Patient recalls Statistical reporting based on ICD-10 coding

EDITOR’S CHOICE

CME: Contraceptive implants (part 2)

This month’s CME continues with the topic of contraceptive implants. Progress in reducing unintended pregnancies in South Africa (SA) is slow. The implant, introduced in 2014, expanded the range of available long-acting reversible contraceptives (LARCs) and held much promise. Uptake has declined precipitously, however, in spite of the ‘unmatched effectiveness’ of the implant and high levels of satisfaction for most users. Policy and provider interventions to raise implant use, underscored by an ‘LARC-first’ approach, are proposed. Contraceptive counselling focuses on the particular benefits of LARCs, and methods are presented in order of effectiveness. Moreover, implants hold particular advantages for certain groups, especially adolescents and young women, in whom they are considered first-line contraception. Provision of immediate postpartum and post-abortion implants is safe and highly acceptable, yet remains under-utilised. Implant services at HIV and tuberculosis clinics are a key priority, as is inclusion of LARC provision in school health services. Implants could also be delivered by existing mobile outreach services, for example in sex worker programmes. Services could be built around nurses dedicated solely to providing implants, with other health workers receiving brief refresher training. Women who experience side-effects, especially abnormal bleeding, require timely interventions following a standardised protocol, including use of medications. Encouraging return for side-effects, follow-up phone calls and home visits would raise continuation rates. Removal services require doctor support or designated nurses at specific centres. Limited access to removal services, health workers’ resistance or botched procedures will further undermine implant provision. Rapid implant demonstration projects in postpartum wards, schools, outreach services and by dedicated providers may rapidly advance the field. Together, the actions outlined will ensure that the implant fulfils its potential and reinvigorates family planning services.

Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in South Africa

A rising caesarean section rate and substandard perioperative care are believed to be the main reasons for recent increases in maternal deaths from bleeding during and after caesarean section (BDACS) in South Africa (SA).[1] The Donabedian model supposes that clinical outcomes are influenced by healthcare workers and the healthcare system. Maswime et al.[1] evaluated near-miss cases from BDACS with regard to health system structure (resources and facilities) and process (patient care). Researchers used a cross-sectional prospective study in greater Johannesburg, SA. Data on women who had near-miss-related BDACS were collected by means of ongoing surveillance at 13 public hospitals. The World Health Organization intervention criteria were used to identify near-miss cases. A comparison of structure and process between the healthcare facilities was conducted. Of 20 527 caesarean sections, there were 93 near misses and 7 maternal deaths from BDACS. Dominant risk factors for near misses were previous caesarean section (43.9%), anaemia (25.3%) and pregnancy-induced hypertension (28.6%). Eighteen women were transferred to higher levels of care, and 8 (44.4%) experienced transport delays of >1 hour. The caesarean section decision-toincision interval (DII) was ≥60 minutes in 77 of 86 women, with an average interval of 4 hours. Structural deficiencies were frequently present in district hospitals, and there were serious delays in ambulance transfer and DIIs at all levels of care.

The majority of the women had risk factors for BDACS. There were major ambulance delays and lack of facilities, mostly in district hospitals. All women required life-saving interventions, but could not access appropriate care timeously. Prevention and management of BDACS require a fully functional health system.

Sensory integration intervention and the development of the premature infant: A controlled trial

Premature infants are at risk of sensory processing difficulties and developmental delays due to an immature central nervous system and possible episodes of medical instability, discomfort, pain and stress during the first weeks or months after birth. Lecuona et al.[2] investigated the effect of Ayres Sensory Integration (ASI) intervention on the development of premature infants in the first 12 months of life. A pre-/post-test experimental design was used to randomly divide 24 premature infants from a low socioeconomic setting in Bloemfontein, SA, into experimental and control groups after being matched by corrected age and gender. Developmental status was determined with the Bayley III Scales of Infant and Toddler Development, the Test of Sensory Functions in Infants and the Infant/Toddler Sensory Profile. The experimental group received 10 weeks of ASI intervention. ASI intervention had a positive effect on the sensory processing and development of premature infants, especially in terms of cogni tive, language and motor development. The authors conclude that ASI intervention at an early age enhances the developmental progress of premature infants.

Access to and utilisation of healthcare services by sex workers at truck-stop clinics in South Africa: A case study

Sex worker-specific health services aim to respond to the challenges that this key population faces in accessing healthcare. These services aim to integrate primary healthcare (PHC) interventions, yet most services tend to focus on prevention of HIV and sexually transmitted infections (STIs). North Star Alliance (North Star) is a public-private partnership providing a healthcare service package in roadside wellness clinics (RWCs) to at-risk populations along transport corridors in sub-Saharan Africa. The study by Fobosi et al.[3] aims to inform future service development for sex workers and describe North Star’s contribution to healthcare provision to this population in SA, including services provided to and utilised by sex workers, and their views of these services. Using a mixed-methods approach, the researchers present quantitative analyses of anonymised North Star routine data for sex workers for October 2013 - September 2015, covering nine sites in seven provinces. Clinic visits were disaggregated by type of service accessed. A thematic analysis of 25 semi-structured interviews conducted at five clinics was carried out. A total of 2 794 sex workers accessed RWCs during the 2 years. Sex workers attending clinics were almost exclusively female (98.2%) and aged <40 years (83.8%). The majority were South African (83.8%), except at Musina, where the majority of clients were Zimbabwean. On average, sex workers visited the clinics 1.5 times per person. However, in most cases only one service was accessed per visit. PHC services other than for HIV and STIs were accessed more commonly than HIV-specific services and STI treatment. There was an increase in the number of services accessed over time, the figure almost doubling from 1 489 during the first year to 2 936 during the second year. Although during recruitment participants reported

November 2017, Print edition

EDITOR’S CHOICE

having had sex in exchange for goods or money during the past 3 months, not all participants self-identified as sex workers during interviews; however, all reported feeling at higher risk of poor health than the general population owing to their involvement in sex work. Participants reported satisfaction with site accessibility, location and operating hours. Sex workers accessing sites described services as being suitable and accessible, with friendly staff. RWCs were highly appreciated by the users, as they are suitable and accessible. The sex workers who used the clinics visited them irregularly, mostly for PHC services other than HIV and STIs. Services other than the one for which the sex worker came to the clinic rarely appeared to be offered. Areas for service expansion are recommended.

Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XL-MAC system

Erroneous weight estimation during the management of emergency presentations in children may contribute to patient harm and poor outcomes. The PAWPER (Paediatric Advanced Weight Prediction in the Emergency Room) XL tape is an accurate length-based, habitusmodified weight estimation device, but is vulnerable to errors if subjective visual assessments of children’s body habitus are incorrect or erratic. Mid-arm circumference (MAC) has previously been used as a surrogate indicator of habitus, and the objective of the study by Wells et al.[4] was to determine whether MAC cut-off values could be used

to predict habitus scores (HSs) to create an objective and standardised weight estimation methodology, the PAWPER XL-MAC method. The PAWPER XL-MAC model was developed by creating MAC ranges for each HS in each weight segment of the tape. This model was validated against two samples, the National Health and Nutrition Examination Survey datasets and data from two previous PAWPER tape studies. The primary outcome measure was to achieve >70% of estimations within 10% of measured weight (PW10 >70%) and >95% within 20% of measured weight (PW20 >95%) for children aged 0 - 18 years. The PAWPER XL-MAC model achieved very high accuracy in the three validation datasets (PW10 79.2%, 79.0% and 81.9%) and a very low critical error rate (PW20 98.5%, 96.0% and 98.0%). This accuracy was maintained across all ages and in all habitus types, except for the severely obese. The PAWPER XL-MAC model proved to be a very accurate, fully objective, standardised system in this study. It has the potential to be accurate across a wide variety of populations, even when used by those not experienced in visual assessment of habitus. BF 1. Maswime TS, Buchmann E. Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in South Africa. S Afr Med J 2017;107(11):1005-1009. https://doi.org/10.7196/SAMJ.2017.v107i11.12340 2. Lecuona E, van Jaarsveld A, Raubenheimer J, van Heerden R. Sensory integration intervention and the development of the premature infant: A controlled trial. S Afr Med J 2017;107(11):976-982. https://doi. org/10.7196/SAMJ.2017.v107i11.12393 3. Fobosi SC, Lalla-Edward ST, Ncube S, et al. Access to and utilisation of healthcare services by sex workers at truck-stop clinics in South Africa: A case study. S Afr Med J 2017;107(11):994-999. https:// doi.org/10.7196/SAMJ.2017.v107i11.12379 4. Wells M, Goldstein LN, Bentley A. Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XLMAC system. S Afr Med J 2017;107(11):1015-1021. https://doi.org/10.7196/SAMJ.2017.v107i11.12505

November 2017, Print edition

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

CORRESPONDENCE

An approach to anaemia diagnosis – concerns in primary care

To the Editor: O’Mahony et al.[1] raise some valid points in their letter published in the October SAMJ. The CME focus[2] was on the approach to diagnosis in patients with anaemia, and so endeavoured to cover as wide a spectrum of causes as possible. As clarified in the preceding editorial,[3] detailed discussion on any particular cause/s was beyond the scope of the CME. More common scenarios in the primary care setting, such as anaemia of chronic disease and iron deficiency anaemia, warrant separate discussion on various platforms. Peripheral blood microscopy in every case was not advocated in the CME, and is not the practice in our institution either. Newgeneration blood-counting analysers supported by sophisticated software obviate the need for microscopy in every sample with anaemia. However, microscopy provides invaluable information on flagged samples, hence its inclusion in the algorithm. The microscopy rate in smaller laboratories that serve primary care centres is generally higher. On the suggestion of incorporating a biochemical approach to the algorithm, serum folate, vitamin B12 and ferritin levels as a starting point resonates a hit-and-miss practice that is likely to prove costly. With regard to discriminating iron deficiency from anaemia of chronic disorders (ACD), soluble transferrin receptor testing is useful, but is not performed by the National Health Laboratory Service (NHLS). It consequently has limited accessibility in the South African (SA) context. Novel parameters generated by automated haematology analysers (such as the reticulocyte haemoglobin content (CHr or Ret-He)) are more widely available, but require insightful interpretation. In our experience, a low Ret-He (<28 pg) usually correlates with reduced/absent bone marrow iron stores in patients with normal/modestly elevated serum ferritin levels. In addition, low Ret-He levels are often noted among hospitalised patients with ACD (raised serum ferritin levels (>400 μg/L) and increased bone marrow iron stores), presumably owing to longstanding functional iron deficiency. As suggested by the authors, further assessment of these and other novel parameters would be useful in the primary healthcare setting. Suspected tuberculosis (TB) and HIV require confirmation through appropriate investigations as mentioned by the authors. Caution is warranted in making a presumptive diagnosis of TB in HIV-positive patients without microbiological evidence, as opportunistic malignancies may have similar symptomatology and radiological findings (including the presence of splenic microabscesses). As stated by the authors, there is no single approach that can fit all scenarios. A stepwise and systematic approach is therefore advocated in the SA setting, viz. a detailed history and a thorough physical examination, followed by laboratory investigations (as per clinical suspicion), including a full blood count. The algorithm for investigation of anaemia uses the full blood count as the base with a specific focus on anaemia. However, it builds on the premise of accurate clinical information and relevant investigations (including laboratory, radiological, etc.) to arrive at the final diagnosis. N Alli, J Vaughan Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, and National Health Laboratory Service, Johannesburg, South Africa nazeer.alli@nhls.ac.za

M Patel Department of Clinical Haematology, Division of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Johannesburg, and School of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 1. O’Mahony D, Mntonintshi M, Parrish AG. An approach to anaemia diagnosis – concerns in primary care. S Afr Med J 2017;107(10):808-809. https://doi.org/10.7196/SAMJ.2017.v107i10.12147 2. Alli N, Vaughan J, Patel M. Anaemia: An approach to diagnosis. S Afr Med J 2017;107(1):23-27. https:// doi.org/10.7196/SAMJ.2017.v107i1.12148 3. Alli N. Anaemia (part 1). S Afr Med J 2017;107(1):23-27. https://doi.org/10.7196/SAMJ.2017. v107i1.12147

S Afr Med J 2017;107(11):928. DOI:10.7196/SAMJ.2017.v107i11.12894

HIV-positive patients in the intensive care unit

To the Editor: We read the retrospective audit by Mkoko and Raine[1] on HIV-positive patients requiring intensive care unit (ICU) admission with great interest. Although we acknowledge that intensive care is a scarce resource in South Africa (SA), and clear guidelines are needed to assist clinicians to allocate resources appropriately, we cannot concur with the authors’ conclusion that ICU care may have to be withheld from HIV patients with higher Acute Physiology and Chronic Health Evaluation ΙΙ (APACHE II) scores and the need for organ support such as renal replacement therapy and inotropes. The authors also erroneously suggest that ‘this is the first study that has determined the outcomes of HIVpositive adults admitted to an SA ICU’. In a prospective study performed by Balkema et al.[2] in the same city (Cape Town, SA), during the same period and on a similar population, ICU mortality of all HIV patients was 38.9%. ICU mortality was associated with an AIDS-defining diagnosis (odds ratio 7.97, p=0.003). Non-survivors had higher APACHE II scores (25.8 v. 18.6; p=0.001) and lower mean admission CD4+ counts (102.5 v. 225.2 cells/µL; p=0.014). Multiple logistical regression analysis confirmed the independent predictive value of World Health Organization (WHO) stage IV disease (p=0.008), lower mean CD4+ counts on admission (p=0.057), and higher APACHE II scores (p=0.010) on ICU mortality, and of WHO stage IV disease (p=0.007) and higher APACHE II scores (p=0.003) on 30-day mortality. In a post hoc analysis, the same investigators retrospectively validated a simple six-point scoring system based on the presence of: (i) AIDS; (ii) a CD4+ count of <50 cells/µL; (iii) extrapulmonary tuberculosis; (iv) Pneumocystis carinii pneumonia; (v) septic shock; and (vi) renal dysfunction. More than 80% of patients with a score of ≥3 died, and no patient with a score of ≥4 survived.[3] The ICU mortality in Mkoko and Raine’s study[1] was 25.3% in patients with a mean (standard deviation) APACHE II score of 21.6 (8.4). This would be anticipated, as the predicted mortality with an APACHE II score in the range of 20 - 24, regardless of HIV status, is up to 40%. Moreover, the APACHE II score was designed as an estimate of mortality after 24 hours of ICU care and not as a guide to offer or withhold critical care.[4] The need for inotropic support is also widely regarded as an independent predictor of mortality in HIV-negative ICU patients. The 47% mortality described in the study would therefore also be anticipated and may not be indicative of mortality specifically attributable to HIV infection in this setting.[5] We therefore cannot concur with the authors’ interpretation to ‘withhold’ ICU care in only the HIV population with these general critical illness severity indices. In the absence of randomised studies or higher levels of evidence, it is still safer to discuss referrals on a case-by-case basis and to consider all comorbidities.

November 2017, Print edition

Makes colon cleansing plain sailing...

Sodium Picosulphate Oral Powder for Solution. For bowel cleansing in conjunction with:

Intravenous Pyelograms (IVP) Bowel Evacuation Abdominal X-Ray Examinations Surgery Colonoscopy S0 Each sachet contains: Sodium Picosulphate 10mg, Magnesium Oxide Ph Eur 3.5g, Citric Acid Ph Eur 12.0g, Aspartame 36mg. Reg.No A38/11.5/0389.

CORRESPONDENCE

A Parker Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa aparker@sun.ac.za

S Lahri Department of Emergency Medicine, Khayelitsha Hospital, Cape Town, South Africa

J J Taljaard Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa

C F N Koegelenberg Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa 1. Mkoko P, Raine RI. HIV-positive patients in the intensive care unit: A retrospective audit. S Afr Med J 2017;107(10):877-881. https://doi.org/10.7196/SAMJ.2017.v107i10.12298 2. Balkema CA, Irusen EM, Taljaard JJ, Zeier MD, Koegelenberg CF. A prospective study on the outcome of human immunodeficiency virus-infected patients requiring mechanical ventilation in a highburden setting. Q J Med 2015;109(1):35-40. https://doi.org/10.1093/qjmed/hcv086 3. Koegelenberg CF, Bulaya T, Balkema CA, Taljaard JJ, Irusen EM. Validation of a severity-of-illness score in HIV-positive patients requiring intensive care unit admission for mechanical ventilation. Q J Med 2016;109(6):434-435. https://doi.org/10.1093/qjmed/hcw061 4. Knaus W, Draper E, Wagner D, Zimmerman J. Apache II: A severity of disease classification system. Crit Care Med 1985;13(1):818-829. 5. Avni T, Lador A, Lev S, Leibovici L, Paul M, Grossman A. Vasopressors for the treatment of septic shock: Systematic review and meta-analysis. PLoS One 2015;10(8):1-17. https://doi/10.1371/journal. pone.0129305

S Afr Med J 2017;107(11):929. DOI:10.7196/SAMJ.2017.v107i11.12907

End-of-life care and organ and tissue donation in South Africa – it’s time for a national policy to lead the way

To the Editor: We refer to the guest editorial in the July SAMJ,[1] which appealed for a national policy to optimise organ donation. The authors highlighted a concerning ‘sense of uncertainty regarding the roles of healthcare professionals in the end-of-life care of terminal patients and procurement of organs from deceased donors’. They also identified the alarming cost to a system that relies on dialysis in the setting of a kidney transplant rate of only 4.1 per million population, and call on the government to create a more effective organ donation policy via so-called ‘national self-sufficiency’. We applaud the authors for promoting improved education for nurses to increase the rates of organ donation in South Africa (SA). Nevertheless, the South African Burn Society was disappointed to note that tissue donation, and specifically donation of skin, was not mentioned, despite the fact that ‘organs and tissue’ should always be introduced together when permission is sought for deceased donation. While organ transplantation and burn surgery are regarded as advanced, centralised subspecialties internationally, only organ transplantation has truly been afforded that status in SA. Burn surgery continues to be poorly resourced and under-staffed despite the extremely high incidence of burn injuries in this country, and there appears to be little desire to improve the situation. Every year more than 3.2 per 1 000 South Africans sustain burn injuries requiring medical attention, and a considerable proportion of these patients are young and/or economically active at the time of their burn.

While many refer to SA’s healthcare service as cripplingly underresourced, there is no doubt that poor resource allocation is also responsible, evident from the perspective of burn services by the fact that other surgical specialties, for example, benefit from considerably more operating time, staffing at all levels, surgical instrumentation and beds in tertiary facilities relative to clinical demand. Misconceptions of the complex interdisciplinary resources required to optimise burn care and outcomes persist. For example, where burn centres do not have their own intensive care facilities, many state-funded intensive care units in SA continue to enforce a policy of denying access to patients with burn injuries, owing to perceived poor outcomes and misplaced concerns about infection prevention and control. It is well recognised that deceased donor allograft is a fundamental resource for the burn surgeon to improve the standard of care of patients with major burn injuries.[2-5] Cadaver skin, when available, has been shown to reduce both mortality and morbidity, and can contribute to reductions in hospital stays and successful societal reintegration. This relies on ready access via skin procurement, processing, banking and distribution. SA has recently established such a skin bank,[4] but cadaver skin continues to be in extremely short supply, ostensibly owing to the absence of a tissue donation culture. The South African Burn Society strongly appeals to the organ donor community to assist us to incorporate discussion about tissue donation, and especially skin, on organ donation platforms, and desist from focusing just on organs, when opportunities such as this arise. We support the authors in motivating for a national policy to improve organ donation, on condition that tissue donation is also part of such a policy. The authors write on behalf of the Executive Committee of the South African Burn Society. N Allorto Pietermaritzburg Hospital Complex and Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

R Moore Chris Hani Baragwanth Academic Hospital and Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

E Andrews Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

R Martinez Red Cross War Memorial Children’s Hospital and Division of Paediatric Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa

W A Smith Kingsbury Hospital, Cape Town, South Africa

V Medapati Department of Plastic and Reconstructive Surgery, School of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa

S L Wall Pietermaritzburg Hospital Complex and Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

November 2017, Print edition

CORRESPONDENCE

A D Rogers Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre and Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Canada alandavid.rogers@sunnybrook.ca

H Rode Red Cross War Memorial Children’s Hospital and Division of Paediatric Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa 1. Fabian J, Crymble K. End-of-life care and organ donation in South Africa – it’s time for a national policy to lead the way. S Afr Med J 2017;107(7):545. https:// doi.org/10.7196/SAMJ.2017.v107i7.12486 2. Rogers AD. Cadaver skin use for burns and complex wounds. Wound Heal South Afr 2013;6(2):54-55. 3. Rogers AD, Allorto NL, Adams S, Adams K, Hudson DA, Rode H. Isn’t it time for a cadaver skin bank in South Africa. Ann Burns Fire Disasters 2013;26(3):142-146. 4. Allorto NL, Rogers AD, Rode H. ‘Getting under our skin’: Introducing allograft skin to burn surgery in South Africa. S Afr Med J 2016;106(9):865-866. https:// doi.org/10.7196/SAMJ.2016.v106i9.10852. 5. Rode H, Martinez R, Rogers AD, Moore R, Allorto NL. Preliminary results of allograft use from the South African skin bank. S Afr Med J 2016:106(11):1059. https://doi.org/10.7196/SAMJ.2016.v106i11.12096

S Afr Med J 2017;107(11):930. DOI:10.7196/SAMJ.2017.v107i11.12810

Medical Malpractice claims above R5m

up 900% since 2009*

Aon is a leading global insurance broker for Medical Malpractice and Professional Indemnity Cover

Speak to an expert Medical Malpractice insurance broker today:

0860 453 672 info@aon.co.za www.aon.co.za *Source: Heath24.com

Aon South Africa (Pty) Ltd is an Authorised Financial Services Provider (FSP #20555).

SURELY THEREâ&#x20AC;&#x2122;S AN APP FOR THAT! Yep, there is...the EMGuidance free mobile app gives you instant access to locally relevant medicines information, clinical guidelines, clinical decision support tools and care coordination information. Your single digital access point. Download it for free from the App Store or Google Play, or scan this QR code.

+2721 461 0228 www.emguidance.com

Launched in mid-2016, Essential Medical Guidance (EMGuidance) is a mobile and web-based clinical support platform which aims to improve patient outcomes by supporting medical professional decision-making at the point-of-care. EMGuidance is accessed via a free iOS & Android application (and web app from December 2017).

EMGuidance is developed by medical professionals, for medical professionals. We believe that: •

By leveraging technology we are able to collaborate and fundamentally change the way medicine is practiced and care is delivered.

•

Technology can empower medical professionals and improve patient outcomes.

•

These technological solutions must be practical, and driven by medical professionals, with a deep understanding of the local healthcare context.

EMGUIDANCE HAS 4 MAIN AREAS 1. The EMGuidance Medicines Section is South Africa’s most comprehensive, interactive and consistently updated, fully-referenced mobile medicines resource, created in partnership with a national network of pharmacologists, specialists & academic institutions. 2. In the Guidelines Section we publish locally relevant clinical guidelines on behalf of over 25 institutional partners. There are over 1,200 guidelines live within the platform. These are geotagged so that our users only see the content most relevant to them. 3. As medical professionals ourselves we understand that the process of managing patients through the system is not as easy as it could be. With this in mind we have created the Care Coordination Section, which details logistical and directory information, such as call rosters and referral information. It is user generated and growing. It’s not perfect yet, but we’re working on it. 4. The EMGuidance Tools Section is a growing library of tools to support point-of-care decision making.

SOME FAST FACTS •

Over 7,000 medical professionals registered and using EMGuidance.

•

More than 1,200 locally relevant clinical guidelines.

•

Over 40 partners adding value to the EMGuidance ecosystem.

•

10 multinational pharma companies adding supplementary and value adding product speciﬁc information within the Medicines Section.

EMGuidance is currently focused on South Africa, however a slimline version is available in most international app stores.

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

IZINDABA

30 days in medicine An hour or two of exercise a week lowers the risk of depression

An 11-year study of 33 908 well adults in the Norwegian Health Study of Nord-Trøndelag County suggests that as little as an hour or two of exercise a week can lower the risk of depression. The risk of developing depression was 44% lower in people who exercised for one or two hours a week than in people who took no regular physical activity. None of the participants had depression or anxiety at baseline, but between 9 and 13 years later 7% of the participants had developed clinically significant symptoms of depression and 8.7% had developed anxiety. Researchers calculated that 12% of the depression cases could have been prevented by low levels of exercise. Harvey SB, Øverland S, Hatch SL, Wessely S, Mykletun A, Hotopf M. Exercise and the prevention of depression: Results of the HUNT Cohort Study. Am J Psychiatry 2017 (epub 3 October 2017). https://doi. org/10.1176/appi.ajp.2017.16111223

Ebola RNA persists in semen of survivors

In a final report published in the New England Journal of Medicine, Deen et al. have shown that Ebola RNA persists in the semen of Ebola virus disease (EVD) survivors. However, this declines over time. Results were from 220 adult male survivors of EVD, 210 of whom had provided an initial semen sample for analysis. Of these men, 27% had positive results and Ebola virus RNA was detected in the semen of all 7 men with a specimen obtained within 3 months of discharge, decreasing to 4% in samples obtained at 16 - 18 months and to zero in men whose sample was obtained at 19 months or later. This study did not look at the risk of sexual transmission of the disease. Deen GF, Broutet N, Xu W, et al. Ebola RNA persistence in semen of Ebola virus disease survivors – final report. N Engl J Med 2017;377:1428-1437. https://doi.org/10.1056/NEJMoa1511410

Childhood obesity rates plateau in the West, but are rising in Asia

The recent NDC Risk Factor Collaboration (NDC-RisC) paper in The Lancet showed that between 1975 and 2016 the proportion of girls worldwide who are obese increased from 0.7% (5 million) to 5.6% (50 million). During the same period, the proportion of boys who are obese rose from 0.9% (6 million) to 7.8% (74 million). The analysis was carried out in 200 countries and pooled 2 416 population-

based studies with height and weight measurements on 128.9 million participants aged ≥5 years, including 31.5 million aged 5 - 19 years. Rates were highest – above 30% – in some islands in Polynesia, and were around 20% or higher in the USA and in some countries in the Middle East and North Africa (e.g. Egypt, Kuwait, Qatar and Saudi Arabia) and the Caribbean (e.g. Bermuda and Puerto Rica). However, while rising trends in body mass index may have plateaued in many high-income countries (at high levels), trends have accelerated in many Asian countries. NCD Risk Factor Collaboration. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017 (epub 10 October 2017). https://doi.org/10.1016/ S0140-6736(17)32129-3

Improved health with modified house design: A study in rural Tanzania

Malaria continues to be a major problem across much of rural Africa. The same population potentially adversely affected by malaria needs affordable housing. Could houses designed in southeast Asia help to prevent malaria in rural Africa? A study by Von Seidlein and colleagues in rural Tanzania suggests that they can. Six prototype houses of southeast Asian design were built in a rural Tanzanian village and compared with modified and unmodified traditional sub-Saharan African houses. The prototypes were built with walls of lightweight permeable materials (bamboo, shade net or timber) with bedrooms raised off the ground with screened windows. Controls were the normal poorly ventilated, wattle-daub or mud-block constructions. In the modified houses, major structural problems such as leaking roofs were repaired, windows were screened, open eaves were blocked with bricks and mortar, cement floors were repaired or constructed and rain gutters and a rain water storage tank were added. The new-design houses had fewer mosquitoes and were cooler than modified and unmodified traditional homes – a novel approach to malaria prevention. Von Seidlein L, Ikonomidis K. Mshamu S, et al. Affordable house designs to improve health in rural Africa: A field study from northeastern Tanzania. Lancet Planetary Health 2017;1(5):e188-e199. https://doi. org/10.1016/S2542-5196(17)30078-5

B Farham Editor ugqirha@iafrica.com

November 2017, Print edition

When you have to be right

UpToDateÂŽâ&#x20AC;&#x201D; access

current, comprehensive clinical content you can trust

With UpToDate, you can easily access more than 10,500 evidence-based, practice-oriented topics covering 24 specialties, making it one of the most comprehensive medical resources available. More than 6,500 expert physician-authors draw from the latest evidence presented in over 440 medical journals, online medical resources and reports by major national and international agencies to provide information you can trust.

Visit go.uptodate.com/SAMJ to learn more.

UpToDate now offers special pricing and convenient ordering for 2 â&#x20AC;&#x201C; 10 individuals.

IZINDABA

OBITUARY Harold James Mons Duncan, 1929 - 2017

I report with much sadness that my great friend and erstwhile partner, the excellent surgeon Harold Duncan, has passed away. Harold was born and spent his childhood in the West Springs Mine area (as did my wife, whom he used to refer to jokingly as his oldest girlfriend). He matriculated at King Edward VII School, where he was a boarder, qualified MB BCh at the University of the Witwatersrand in 1952, and completed his internship in Kroonstad, where he

came under the tuition of the legendary surgeon Prof. Chris Derksen. A later mentor was another excellent surgeon, Prof. Dick Schulenburg, in Pretoria. While in Kroonstad Harold did locums for Dr Alf Robertson, who subsequently moved to Durban, where he built up a shipping practice that was not only successful but required skill in various languages as well as good judgement. Knowing Harold well, Alf referred much of this work to him when Harold joined the practice of Mannie Stein, who had introduced vascular surgery in Natal. Mannie was a very bold surgeon, and I joined him in practice in 1963. Harold and I had a wonderful working relationship, covering each other’s work on Wednesdays and Thursdays so that we could play golf. We shared the railway and harbour intake, working on alternate weeks. The practice was very busy, and we were never short of operating experience. Harold rented a house in Plettenberg Bay, which he subsequently bought, and this changed the lives of his family. He was very generous in allowing us to use it as often as we liked. It was a lovely home, overlooking Outlook Beach and surrounded by rock pools, with a viewing point from which one

November 2017, Print edition

could watch dolphins cavorting in the deep blue sea. He would leave Durban early in the morning and drive straight through to reach this home ten hours later. Harold was a mean golfer, but as a result of locomotor problems due to an arthro desis of his ankle followed by a rupture of the tibialis anterior, he changed to bowls and thoroughly enjoyed the social mix of his fellow bowlers. He was also a prominent member of the Durban Discussion Group, which invited experts in their fields to give talks every month. Always popular and always modest, he had a spontaneous and cutting sense of humour, but was never cruel. Harold’s lovely wife Pam died in 2004 from a highly malignant ovarian tumour, after which he spent time living with his children and grandchildren in Durban. He was then fortunate to find companionship with Mary Ross, a widow, and they lived alternately in Stellenbosch on a wine farm and in Plettenberg Bay. He will be sorely missed by his children, Peter, Ann and Janet, and his grandchildren. Roy Wise Durban, South Africa wisel@mweb.co.za

XTANDITM offers significant improvements in overall survival while maintaining quality of life, vs. placebo * XTANDITM delays the time to chemotherapy from months to years 2 ** A generally well tolerated treatment, with dosing that’s simple and convenient 1, 2, 3 * in patients both before and after chemotherapy 2, 3 ** in chemo naïve patients

Treat what really matters in mCRPC, treat with XTANDI TM

References: 1. XTANDITM Package insert dated 30 September 2016. 2. Beer TM, Armstrong AJ, Rathkopf DE et al. Enzalutamide in Metastatic Prostate Cancer before Chemotherapy. N Engl J Med 2014;371(5):424-433. 3. Scher HI, Fizazi K, Saad F et al. Increased Survival with Enzalutamide in Prostate Cancer after Chemotherapy. N Engl J Med 2012;367(13):1187-1197. For full prescribing information refer to the package insert approved by the Medicines Regulatory Authority. S4 XTANDITM 40 mg soft capsules. Reg. No. 48/26/0404. Each soft capsule contains 40 mg of enzalutamide. Applicant: Astellas Pharma (Pty) Ltd, Reg. No. 2002/024956/07, EOH Business Park, Gillooly’s View, 5 Osborne Lane, Bedfordview, 2007, Tel: 011 615 9433, Fax: 011 615 9427 x/LakeA4add/6-8-2015 18204

18205 Xtandi A4 Advert LAKE ®®.indd 1

9/29/17 11:47 AM

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

CME

Lessons learnt from the introduction of the contraceptive implant in South Africa M Pleaner,1 MEd; C Morroni,1,2,3,4 MB ChB, DFSRH, DTM&H, MPH, MSc, PhD; J Smit,5 BPharm, MSc, PhD; N Lince-Deroche,6 MIA, MPH, PhD; M F Chersich,1 MB BCh, PhD; S Mullick,1 MB ChB, MSc, MPH, PhD; D Pillay,1 MPH; M Makua,7 DLitt et Phil, MTech; H Rees,1 MB BChir, MA (Cantab), MRCGP, DCH, DRCOG Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 3 EGA Institute for Women’s Health and Institute for Global Health, University College London, UK 4 The Botswana-UPenn Partnership, Gaborone, Botswana 5 Maternal Adolescent and Child Health (MatCH) Research Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KwaZulu-Natal; and School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 6 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 7 National Department of Health, Pretoria, South Africa 1 2

Corresponding author: M Pleaner (mpleaner@mweb.co.za)

In 2014, South Africa (SA) introduced the subdermal contraceptive implant with the aim of expanding the contraceptive method mix and availability of long-acting reversible methods in the public sector. Three years on, concerns have been raised about the decline in uptake, early implant removals and challenges in service delivery. This article explores the lessons learnt from the introduction of contraceptive technologies elsewhere and applies these to the SA context. Drawing on the World Health Organization’s conceptual framework for the introduction of new contraceptive methods, and subsequent literature on the topic, lessons are classified into six cross-cutting themes. Recommendations highlight the need for SA to review and explore strategies to strengthen current implant services, including the provision of improved provider training aimed at sensitive, client-centred approaches; increased community engagement; and improved systems for programmatic monitoring and evaluation. With implementation of these recommendations, worrying trends in the provision of implants could be reversed. S Afr Med J 2017;107(11):933-938. DOI:10.7196/SAMJ.2017.v107i11.12805

This article explores the complexities of introducing new contra ceptive technologies and applies these to the initiation of the subdermal contraceptive implant (implant) in the South African (SA) context. Using the World Health Organization (WHO)’s conceptual framework[1,2] and other emerging literature, lessons are identified and key recommendations proposed. Over the past decade there have been concerted efforts to promote long-acting reversible contraceptive (LARC) methods in sub-Saharan Africa, especially the implant and the copper intrauterine device (IUD).[3,4] These methods have high continuation rates compared with other methods and very high effectiveness (<1 unintended preg nancy per 100 women-years).[5] It is estimated that almost 2 million unintended pregnancies could be averted over 5 years if only 20% of women in sub-Saharan Africa, currently using shorter-acting methods (oral contraceptives or injectables), switched to the implant.[6] In this region, the contraceptive method mix has long been dominated by these shorter-acting methods, which, when used correctly, are highly effective and acceptable to women. However, these methods are also associated with significant rates of discontinuation, incorrect use, poor adherence and consequent unintended pregnancy.[7] Similarly, SA’s most commonly used contraceptive methods are the injectables,[8] depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN), which account for half of contraceptive use nationally.[9,10] The implant is registered for use in more than 100 countries worldwide,[11] including many in sub-Saharan Africa, where use has increased rapidly over the past decade.[12,13] In 5 years, uptake doubled

in Malawi, quadrupled in Tanzania, and rose more than 15-fold in Rwanda and Ethiopia.[12,14,15] In Zimbabwe, for example, implant use increased from <1% in 1994 to 10% by 2015.[16] In 2014, SA introduced the implant – somewhat later than other countries in the region – in an effort to expand its method mix and especially to increase access to LARCs, which have been given centre place in the country’s contraception policy.[17,18] Aside from the effectiveness of LARC methods and the benefits of increasing method choice,[19,20] the possible links between injectables (particularly DMPA) and risk of HIV acquisition provided an impetus for the introduction of alternative methods in SA.[18,21,22] The launch of the implant in SA was accompanied by much excitement and anticipation – it was the first new method introduced in the public sector in almost 20 years. Implant services were described as ‘the biggest family planning programme SA has ever seen’,[23] with ≥6 000 healthcare providers trained with regard to implant provision, with a focus on insertion. Both the 5-year, two-rod levonorgestrel implant (Jadelle) and the 3-year, single-rod etonogestrel implant (Implanon NXT) were registered with the SA Medicines Control Council for use, but only Implanon NXT was made available in public health clinics as part of the national contraception programme. Estimates of implant uptake in the year after launch ranged from 176 000, based on data reported to the District Health Information System (DHIS), to as high as 900 000, according to the Department of Health.[24,25] Data from the subsequent years, however, showed an almost 50% decrease in insertion numbers year on year.[26] The number of insertions dipped considerably across all districts that reported these data

November 2017, Print edition

CME

(Table 1, Fig. 1). The Demographic and Health Survey (2016) estimated plant use at 8% for married and sexually active unmarried im women.[10] Actual numbers of removals are not known, because these were not initially systematically recorded. However, some reports in the media suggested that early removals were common and that women faced difficulties in getting implants removed because of healthcare-provider resistance to removal.[27,28] Therefore, while the introduction of the implant heralded an important step towards the strengthening of SA’s contraception programme, and brings the country on par with its regional counterparts in terms of wider method choice, SA’s implant programme is facing several challenges. Many of these challenges are common to the introduction of new contraceptive technologies elsewhere. On occasion, the roll-out of a new contraceptive method has been undermined by adverse events and negative user experiences related to inadequate quality of care, which even if uncommon, have resulted in adverse publi city, rumours and misperceptions. It is, therefore, timely and critical to reflect on lessons learnt from the early period of implant avail Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northern Cape North West Western Cape

30 000

Implants, n

20 000

10 000

-S

Ap r

-J un

e2 0 ep 14 t2 Oc 01 t4 D Jan ec 2 - M 014 Ap ar 2 rJu 015 ne Ju ly 20 -S 15 e Oc pt 2 0 t15 D Jan ec 2 0 15 -M ar Ap 20 r16 J Ju une ly - S 2016 e Oc pt 2 01 t6 D Jan ec 2 0 16 -M ar 20 17

Fig. 1. Implant insertions in SA by province (April 2014 - March 2017).[26] (No data are available for the Eastern Cape, the Free State, Mpumalanga, North West and the Western Cape before April - June 2015.)

ability in SA, based mainly on the experiences and insights of the authors, all of whom are closely involved in the SA contraception programme. These lessons are placed in the context of similar expe riences of contraceptive introduction elsewhere. We classify these findings into six thematic areas, drawing on a WHO conceptual framework for the introduction of a contraceptive method,[1,2] as well as subsequent literature on the topic.[29-33] We then propose key steps that could reinforce and reconfigure the implant programme in SA.

Lessons learnt – six thematic areas

1. Learn from the ‘boom-and-bust’ phenomenon in family planning

The term ‘boom-and-bust’ in family planning describes the pheno menon in which there is an initial boom in the use of a new contra ceptive technology, coupled with excitement and optimism, followed by a rapid downturn due to unmet expectations and disappointment – the ‘failed promise of the contraception revolution’.[33] Several contraceptive methods have had a particularly turbulent history, as summarised in Box 1. Concerns have been raised about the potential for the implant to follow a similar trajectory if lessons from the past are not heeded.[15] Importantly, the boom-and-bust phenomenon in family planning can have far-reaching, long-term, negative consequences, creating a climate of mistrust and lack of confidence in a method, or even in family planning services, more broadly. These effects may be experienced many years afterwards – for both providers and consumers – and may result in withdrawal of the method.[2] The boom-and-bust concept explicitly acknowledges the impor tance of closely monitoring the introduction of a new method, and then swiftly recognising and addressing the causes of any downward turn in uptake or acceptability more generally. Accurate data on uptake, pharmacovigilance, and levels of discontinuation or removal and reasons thereof are especially important.

2. Promote informed choice

In the enthusiasm of introducing a new, promising contraceptive meth od, there may be a tendency to promote that method over others,[2,7,37] both programmatically and at the level of individual provider-client interactions. This bias, which may be overt or subtle, may result in the provision of incomplete information and counselling, the over-selling

Table 1. Contraception methods dispensed, 2013/2014 - 2015/2016[26] Type of contraceptive dispensed Female condoms IUD inserted Male condoms Medroxyprogesterone Norethisterone enanthate Oral pill cycles Sterilisation female Sterilisation male Subdermal implant inserted Total

2013/2014 Contraceptive n years dispensed 13 254 328 66 271 41 817 167 268 506 431 299 2 532 156 5 762 721 1 440 680 4 277 194 712 865

2014/2015 Contraceptive n years dispensed 21 099 517 105 497 39 168 156 672 712 387 234 3 561 936 5 510 430 1 377 607 3 834 005 639 000

2015/2016 Contraceptive n years dispensed 27 005 805 135 029 15 150 60 600 839 874 751 4 199 373 5 578 228 1 394 557 3 676 445 621 740

Change 2014/ 2015 - 2015/ 2016, % 28 -61.3 17.9 1.2 -4.1

3 815 539 31 551 1 120 -

293 503 631 020 11 200 -

3 560 421 32 074 877 175 948

273 878 641 480 8 770 527 844

3 591 382 33 134 772 87 189*

276 260 662 681 7 720 261 567

0.9 3.3 -12 -50.4

5 854 963

7 292 684

7 619 527

4.4

IUD = intrauterine device. *Subdermal implants for 2015 - 2016 were reported by only four provinces.

November 2017, Print edition

CME

Box 1. Boom-and-bust of contraception methods • The Lippes Loop IUD, introduced in 1960, was aggressively promoted in India, with ‘loop squads’ and cash incentives, and >2 million insertions were done between 1965 and 1967.[34] Very high levels of early removal have been mostly attributed to over-zealous persuasion of women to use the IUD, with little attention to method choice, counselling about method disadvantages, and possible side-effects, e.g. bleeding and cramping. The India Family Planning Programme also failed to address widespread rumours, misconceptions and cultural issues relating to the device.[34] The shortcoming of the Lippes Loop introduction negatively impacted IUD use in India for many years.[1,35] • The Dalkon Shield IUD, which was introduced as a ‘safe’ alternative to the oral contraceptive pill in the 1970s, was the target of legal action in the USA, and the subject of extensive negative publicity, and was ultimately removed from the market. While removal of the device was justified, as it was determined that a structural flaw in the device caused septic abortions and pelvic infections, this controversy contributed to negative perceptions about safer, new-generation IUDs, and is partially responsible for the lingering, even though now disproven, concerns about IUDs causing pelvic inflammatory disease.[36] This experience highlights the need to invest effort in debunking misconceptions and providing correct information. • Another example is provided by Norplant. This six-rod subdermal progestin-only implant, was seen as a major breakthrough in contraceptive technology when it was introduced in several countries, including the USA, UK and Indonesia, in the 1990s. Accusations of failure of the manufacturer to disclose side-effects led to litigation in the USA. Although the litigation was ultimately unsuccessful, it was accompanied by negative publicity and, along with problems in other countries, contributed to Norplant’s withdrawal from the market in 2006.[29] Other problems with Norplant related to quality of care, including mass insertions, called ‘safaris’ in Indonesia, leading to perceptions of client coercion;[30] inadequate provider training and lack of competency in insertion and removal; accusations of healthcareworker resistance to removal; and poor-quality counselling.[31]

of the benefit of the new method, a lack of acknowledgment that each contraceptive method comes with advantages and disadvantages, and that the importance of these differ from person to person. Within the early stages of the implant programme in SA, concerns arose that con traceptive users were not being given an adequate choice of methods, with the implant being strongly promoted as the first-line method, and with insufficient counselling about possible side-effects or alternative contraceptive options.

3. Avoid over-emphasis of method technology and technological advantages

A focus on technological advantages of the implant, e.g. its longterm action, high efficacy and cost-effectiveness, may overshadow a woman’s personalised experience of the method, especially the impact and tolerability of side-effects. Most importantly, a preoccupation with the long-acting dimensions of the LARCs can result in preeminence being given to the continuation rate as the indicator of success and acceptability. If that occurs, then early removal is seen as problematic and even as wasteful, and may generate resistance among healthcare providers to performing early removals.[31] In SA, an over-emphasis on the notion of ‘3 years of use’ perhaps has meant that the programme did not adequately anticipate and prepare for early removals, as these were viewed as signalling a failure of the programme rather than merely a reflection of the varying needs of women over time, which is to be expected and should be planned for. Implant removals are common across all settings. For example, about a quarter of women discontinued within the first year of use in studies in the Netherlands,[38] the UK and Australia,[39,40] as well as other settings.[14,15] Also, the reality of early removal levels may not always match perceptions, e.g. in Ethiopia concerns arose about early removals, but an evaluation showed that only ~2% of implant users had discontinued the method by 6 months.[41] It is important to keep implant removals in perspective – because the implant requires healthcare-provider intervention for removal, providers generally hear of and see women who are dissatisfied with the method and/or who request removals, and not the many ‘silent’ women who are satisfied with the method and only return to the clinic after 3 years. Furthermore, healthcare providers are generally not accustomed to having to actively manage discontinuation of contraceptives. Women discontinue pills or injections on their own,

contributing to the perception that there is a higher rate of implant discontinuation compared with other methods. Conceptually, thinking and language need to move away from the notion that the implant is designed to be used for a certain number of years, to the more nuanced message that it can be used for a number of years if women choose to do so.[1,31,42] Key to improving implant provision is understanding the reasons for early removals, e.g. are these due to inadequate counselling; dissatisfaction with the method; lack of support while using the method, including assistance in dealing with side-effects; or women no longer being sexually active or wanting to become pregnant?

4. Focus on quality standards and overall access, rather than targets for an individual method

Internationally, it is common practice to make contraceptive programmes heavily target driven, and although this is often well intentioned, it may compromise quality of care.[15] An example is target setting for training, which occurred in SA, with a focus on numbers of providers trained, rather than on quality of training and documenting provider proficiency outcomes. The number of devices inserted is also often target driven, and can occur at the expense of oversight of the quality of care provided.[42,43] While there are merits to setting targets, e.g. around overall contraceptive prevalence in a country, indicators need to centre around access, which includes dimensions such as quality of services and client satisfaction, rather than merely uptake.

5. Adoption of innovative, acceptable and comprehen sive service-delivery models

Innovative models of service delivery warrant consideration, drawing on experiences from other settings. For example, the use of dedicated, specially trained providers might be more appropriate where new clinical skills, such as implant removals, are difficult to roll out to large numbers of providers. In 2008 - 2009, Zambia trained 18 retired midwives and deployed them to high-volume, public-sector facilities, solely for the provision of LARC services over 14 months, which showed a marked increase in uptake over a short period of time.[14,44] A key challenge for implant service delivery is getting the balance right in relation to training on insertions and removals. The pattern of introducing implants and focusing training on insertions and not

November 2017, Print edition

CME

on removals, has repeated itself across countries.[14,19] This approach is based on the assumption that there would be a window of several years in which to do this training. Also, practically, it is difficult for healthcare providers to learn how to perform removals at the onset of a programme, when few insertions have been made. Often, there is intent to do training on removals, but once the implant is introduced the momentum for training dissipates. Clearly, access to quality removal services from the onset of an implant programme is essential. Many countries have underestimated the number of women who would request removals before 3 years.[14,15] Failure to provide accessible removal services is an infringement of women’s rights, and may impact negatively on the community’s perception of the implant. Expanding the choice of contraceptive methods does not necessarily result in increased utilisation if constraints in the health system and the needs of the end user are not taken into account.[2,31] A holistic perspective is called for, tailored to the social, cultural, and personal norms and values that influence patterns of use in a particular context. Such a perspective explicitly acknowledges that the implant is most often used by healthy women, who may not be willing to accept sideeffects,[37,45] many of which are genuinely uncomfortable.[2,14,45] The needs of women also change with age. Of note, adolescents have specific considerations, which are best met within the context of youth-sensitive services.[46-48] Little has been done to promote the implant among SA adolescents, with a commonly held perception that the method is more suitable for adults. Several studies, however, show that the implant is highly acceptable to young women,[49,50] with continuation rates of ~80% after 12 months,[51] including in studies in sub-Saharan Africa.[52] Lastly, the importance of demand creation, community engage ment, sensitisation and addressing of concerns as they relate to a woman’s life and context requires emphasis.[53] This involves generating a dialogue and structured engagement with programme planners, health workers, communities and end users to identify and address barriers.[14,32,53] Non-governmental organisations, researchers and technical assistance agencies could all make an important contribution to such efforts.

6. Ensure a rights-based approach

The abovementioned lessons draw together important strands, which locate the promotion of the implant within the context of sexual and reproductive health and rights.[13,54-57] A rights-based approach is especially important given that, historically, family planning programmes in SA have been associated with coercion.[58,59] Most importantly, services must take into account the gamut of social, cultural and relational factors that influence contraceptive uptake and continued use. Each new method carries a set of trade-offs for healthcare systems, providers and end users that will influence acceptability and continued use.[2] Therefore, optionsbased, rather than directive counselling, is required, so that the implant is not recommended above other methods. Effectiveness is only one of many criteria that determine the optimum method for a woman at a particular point in time, and other factors may guide her choice, including how frequently she has sex, her partner’s involvement, her fertility desires, and cultural or personal issues relating to side-effects. Sensitivity and attention to these dimensions ensure that clients are informed and have agency regarding method selection, and continuing or discontinuing use.

Recommendations

Based on the lessons described above, we propose the following priority recommendations to support SA’s implant programme:

Capacity building for healthcare providers

• The expanded provision of new and refresher training courses for healthcare providers, which cover technical skills around insertion and removal, informed decision-making and choice for women, pre-insertion counselling, especially around side-effects, and longterm support and management of side-effects. • Capacity building needs to strengthen provider confidence and competence in insertions and removals, recognising that this requires an investment in quality training, effective supervision, structured mentorship and accessible on-site support. • Training and support need to include more nuanced counselling, which should address issues such as changes in bleeding patterns and how this may affect women’s lives, e.g. the cost of sanitary wear and sexual relationships. Reassurance and competent management of side-effects play a major role in determining whether a woman chooses to continue the method. • A skills and human resource assessment needs to be done, espe cially in relation to implant removals, and measures should be put in place to address gaps. • Training needs to focus on the most recent WHO medical eligi bility criteria guidance for the implant, in particular the suitability of implants for women of all ages, including adolescents, and highlight potential advantages of the method for this group.

Clear communication to healthcare providers and end users regarding drug interactions

• Clear communication needs to be provided for both healthcare providers and end users where drug interactions might be a potential problem, including for those on treatment for tuberculosis (TB), HIV or epilepsy.[60,61] In the presence of ambiguity, healthcare providers understandably err on the side of caution, either not offering implants to potentially eligible women or unnecessarily encouraging removal.

Data collection and monitoring systems

• Address data gaps in recording of uptake, removals and pharmaco vigilance, including use of the implant in women with medical conditions such as epilepsy, HIV and TB. • Disaggregate implant data by age (especially to identify use among adolescents and young women) and by specific groups of women, such as postpartum and post-abortion patients. This can then be used to identify gaps in provision, training, quality of care, and factors influencing uptake and continuation.

Increase demand

• Adopt innovative service-delivery models, which could include ‘re-introducing’ the implant (and other LARC methods, such as the IUD) in selected districts; engage with communities in terms of myths, misconceptions and women’s experiences with the method; and debrief healthcare providers about their experiences with the method and their concerns.

Assess the feasibility of further expanding the contraceptives available in the public sector

• Contraceptive use may be increased by expanding the range of methods available to accommodate different needs.[20] The SA contra ception policy recommended a 5-yearly review (2012 - 2017).[17,62] This is now imminent and presents a window of opportunity to review the guidelines. More specifically, based on the concerns raised in this article, the review should consider uptake of and barriers to the use of all methods. With the emergence of new data, further consideration should be given to different contraceptives among women at risk of HIV and those

November 2017, Print edition

CME

infected with HIV or TB, including guidance on contraceptive prescribing and drug interactions.

Conclusion

Problems and challenges encountered during the introduction phase of the contraceptive implant in SA are not unique, and mirror experiences elsewhere. Lessons learnt elsewhere provide valuable insights about the health-system elements required to support service provision and demand creation, as well as ensuring that these take place within a rights-based framework. It is critical to heed these lessons, identify and analyse problems and deal with them effectively to ensure success of implant introduction. Real or perceived concerns about new methods, such as the implant, may discredit the use of methods by current and potential users, communities and healthcare providers. It is imperative that the potential contribution of the implant to women’s health in SA is not undermined by unsubstantiated negative publicity and misconceptions, or by the unwarranted importance assigned to removal rates not supported by data. Addressing the skewed contraceptive method mix in SA and promoting a greater choice of methods, including the implant, require nuanced provider training and sensitivity, novel health-system support, intensive community engagement, consumer awareness, and systems for programmatic monitoring, evaluation and quality improvement. While this article specifically addresses issues relating to implants, many of these reflections may apply to the strengthening of other LARC methods, such as the IUD, and indeed, the contracep tive programme as a whole. Acknowledgements. A word of appreciation to Dr Manala Makua for her feedback and guidance, and to the collective contribution of the authors for the evolution and completion of this article. A special word of thanks to Candy Day (Health Systems Trust) for providing updated DHIS data, and Alida Gertz (Afya Bora Global Health Fellow, The Botswana-UPenn Partnership) for assistance with designing Fig. 1. Author contributions. MP: conceptualised the article and worked on it to completion; CM, JS, NL-D: reviewed and assisted with the development of the initial drafts; MFC, HR, SM, DP, MM: edited and revised subsequent drafts; and CM, HR, MFC: read and approved the final manuscript. Funding. None. Conflicts of interest. None. 1. World Health Organization. Expanding Family Planning Options: Contraceptive Introduction Reconsidered: A Review and Conceptual Framework. Geneva: WHO, 1994. 2. Simmons R, Hall P, Díaz J, Díaz M, Fajans P, Satia J. The strategic approach to contraceptive introduction. Stud Fam Plann 1997;28(2):79-94. https://doi.org/10.2307/2138111 3. Ngo TD, Nuccio O, Pereira SK, Footman K RK. Evaluating a LARC expansion program in 14 subSaharan African countries: A service delivery model for meeting FP2020 goals. Matern Child Health J 2016;21(9):1734-1743. https://doi.org/10.1007/s10995-016-2014-0 4. Staveteig S, Mallick L. Uptake and discontinuation of longacting reversible contraceptives (LARCs) in low-income countries. DHS Anal Stud 2015;(54). 5. Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal DPM, eds. Contraceptive Techology. 20th rev. ed. New York: Ardent Media, 2011. 6. Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in sub-Saharan Africa: Magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception 2008;78(1):73-78. https://doi.org/10.1016/j.contraception.2008.03.002 7. Bertrand JT, Sullivan TM, Knowles EA, Zeeshan MF, Shelton JD. Contraceptive method skew and shifts in method mix in low- and middle-income countries. Int Perspect Sex Reprod Health 2014;40(3):144-146. https://doi.org/10.1363/4014414 8. Baumgartner JN, Morroni C, Mlobeli RD, et al. Timelines of contraceptive reinjections in South Africa and its relation to unintentional discontinuation. Int Fam Plan Perspect 2007;33(2):66-74. https://doi. org/10.1363/ifpp.33.066.07 9. Chersich MF, Wabiri N, Risher K, et al. Contraception coverage and methods used among women in South Africa: A national household survey. S Afr Med J 2017;107(4):307-314. https://doi.org/10.7196/ SAMJ.2017.v107i4.12141 10. Department of Health, Statistics South Africa, South African Medical Research Council. South African Demographic and Health Survey 2016: Key Indicators. Pretoria: SSA, 2017. 11. Lince-Deroche N, Pleaner M, Harries J, et al. Achieving universal access to sexual and reproductive health services: The potential and pitfalls for contraceptive services in South Africa. In: Padarath A, King J, Mackie E, Casciola J, eds. South African Health Review 2016. Durban: Health Systems Trust, 2016. 12. United States Agency for International Development. Three Successful Sub-Saharan Africa Family Planning Programs: Lessons for Meeting the MDGs. Washington DC: USAID, 2012:1-31.

13. Hardee K, Harris S, Rodriguez M, et al. Achieving the goal of the London summit on family planning by adhering to voluntary, rights-based family planning: What can we learn from past experiences with coercion? Int Perspect Sex Reprod Heal 2014;40(4):206-214. https://doi. org/10.1363/4020614 14. Jacobstein R, Stanley H. Contraceptive implants: Providing better choice to meet growing family planning demand. Glob Health Sci Pract 2013;1(1):11-17. https://doi.org/10.9745/ghspd-12-00003 15. Hubacher D, Dorflinger L. Avoiding controversy in international provision of subdermal contraceptive implants. Contraception 2012;85(5):432-433. https://doi.org/10.1016/j.contraception.2011.11.018 16. Zimbabwe National Statistics Agency and ICF International. Zimbabwe Demographic and Health Survey 2015: Final Report. Rockville, Md, USA: ZIMSTAT and ICFI, 2016. 17. Department of Health. National Contraception and Fertility Planning Policy and Service Delivery Guidelines. Pretoria: DoH, 2012. 18. Department of Health. National Contraception Clinical Guidelines. Pretoria: DoH, 2012. 19. Hubacher D, Dorflinger L. Avoiding controversy in international provision of subdermal contraceptive implants. Contraception 2012;85(5):432-433. https://doi.org/10.1016/j.contraception.2011.11.018 20. Ross J, Stover J. Use of modern contraception increases when more methods become available: Analysis of evidence from 1982 - 2009. Glob Health Sci Pract 2013;1(2):1-10. https://doi.org/10.9745/ ghsp-d-13-00010 21. World Health Organization. Hormonal contraception and HIV. 2012. http://www.who.int/reproductivehealth/ topics/family_planning/Hormonal_contraception_and_HIV.pdf (accessed 1 September 2017). 22. World Health Organization. Hormonal Contraceptive Eligibility for Women at High Risk of HIV: Guidance Statement Recommendations Concerning the Use of Hormonal Contraceptive Methods by Women at High Risk of HIV. Geneva: WHO, 2017. 23. http://www.bdlive.co.za/national/health/2014/02/20/new-contraceptive-implant-free-to-women-in-sasays-motsoaledi (accessed 5 March 2016). 24. Department of Health. The Contraceptive Implant in South Africa. Pretoria: DoH, 2015. 25. Massyn N, Day C, Peer N, Padarath A, Barron P, English R. District Health Barometer 2013/14. Durban: Health Sytems Trust, 2014. 26. Massyn N, Peer N, Padarath A, Day C, eds. District Health Barometer 2016/17. Durban: Health Systems Trust, 2017. 27. Ina S. Birth control implant needs a shot in the arm. Mail and Guardian. 22 May 2015. http://women. mg.co.za/birth-control-implant-needs-a-shot-in-the-arm/ (accessed 5 March 2016). 28. ENCA. Checkpoint-Implanon update. https://www.enca.com/media/video/implanon-update? (accessed 5 March 2016). 29. Hardee K, Balogh S, Villinski MT. Three countries’ experience with norplant introduction. Health Policy Plan 1997;12(3):199-213. https://doi.org/10.1093/heapol/12.3.199 30. Population Council New York. Jadelle Levonorgestrel Rod Implants: A Summary of Scientific Data and Lessons Learned from Programmatic Experience. New York: PCNY, 2002:1-58. 31. Institute of Medicine. Contraceptive Research, Introduction, and Use: Lessons from Norplant. Washington, DC: National Academies Press, 1998. 32. Simmons R, Hall P, Diaz J, Diaz M, Fajans P, Satia J. The strategic approach to contraceptive introduction. Stud Fam Plann 1997;28(2):79-33. https://doi.org/10.2307/2138111 33. Boonstra H, Duran V, Northington Gamble V, Blumenthal P, Dominguez L, Pies C. The ‘boom and bust phenomenon’: The hopes, dreams, and broken promises of the contraceptive revolution. Contraception 2000;61(1):9-25. https://doi.org/10.1016/s0010-7824(99)00121-3 34. Solinger R, Nakachi M, eds. Reproductive States: Global Perspectives on the Invention and Implemen tation of Population Policy. Oxford: Oxford University Press, 2016. 35. Hafez ES, van Os WA, eds. Medicated Intrauterine Devices: Physiological and Clinical Aspects. Developments in Obstetrics and Gynaecology. Rotterdam: Springer, 1980:188. 36. Thiery M. Intrauterine contraception: From silver ring to intrauterine contraceptive implant. Eur J Obstet Gynecol Reprod Biol 2015;90(2):145-152. https://doi.org/10.1016/s0301-2115(00)00262-1 37. Rowlands S, Searle S. Contraceptive implants: Current perspectives. J Contracept 2014;5:73-84. https:// doi.org/10.2147/oajc.s55968 38. Teunissen AM, Grimm BRF. Continuation rates of the subdermal contraceptive Implanon® and associated influencing factors. Eur J Contracept Reprod Health Care 2014;19(1):15-21. https://doi.org/ 10.3109/13625187.2013.862231 39. Lakha FGA. Continuation rates of Implanon in the UK: Data from an observational study in a clinical setting. Contraception 2006;74(4):287. https://doi.org/10.1016/j.contraception.2006.05.072 40. Harvey C, Seib C, Lucke J. Continuation of family, rates and reasons for removal among Implanon® users accessing two planning clinics in Queensland, Australia. QUT Digit Repos 2009;80(6):527-532. https:// doi.org/10.1016/j.contraception.2009.05.132 41. Kidane A, Asefa T, Asres T, et al. Assessment of implant and IUCD removal in Ethiopia. International Conference on Family Planning Research and Best Practices, Kampala, Uganda, November 2009. http://fpconference.org/2009/media/DIR_169701/15f1ae857ca97193ffff83acffffd524.pdf (accessed 5 March 2016). 42. Bertrand JT, Hardee K, Magnani RJ, Angle MA. Access, quality of care and medical barriers in family planning programs. Int Fam Plan Perspect 1995;21(2):64-74. https://doi.org/10.2307/2133525 43. RamaRao S, Lacuesta M, Costello M, Pangolibay B, Jones H. The link between quality of care and contraceptive use. Int Fam Plan Perspect 2003;29(2):76-83. https://doi.org/10.2307/3181061 44. Neukom J, Chilambwe J, Mkandawire J, Mbewe RKH. Dedicated providers of long-acting reversible contraception: New approach in Zambia. Contraception 2011;83(5):447-452. https://doi.org/10.1016/j. contraception.2010.08.021 45. Dickerson LM, Diaz VA, Jordon J, et al. Satisfaction, early removal, and side effects associated with longacting reversible contraception. Fam Med 2013;45(10):701-707. 46. Chandra-Mouli V, McCarraher DR, Phillips SJ, Williamson NE, Hainsworth G. Contraception for adolescents in low and middle income countries: Needs, barriers, and access. Reprod Health 2014;11(1):1. https://doi.org/10.1186/1742-4755-11-1 47. Chandra-Mouli V, Greifinger R, Nwosu A, et al. Invest in adolescents and young people: It pays. Reprod Health 2013;10(1):51. https://doi.org/10.1186/1742-4755-10-51 48. Hubacher D, Olawo A, Manduku C, Kiarie J. Factors associated with uptake of subdermal contraceptive implants in a young Kenyan population. Contraception 2011;84(4):413-417. https://doi.org/10.1016/j. contraception.2011.02.007 49. McNicholas C, Peipert JF. Long-acting reversible contraception (LARC) for adolescents. Curr Opin Obstet Gynecol 2012;24(5):293-298. https://doi.org/10.1097/gco.0b013e32835686d5 50. Committee on Adolescents. Contraception for adolescents. Policy statement. Pediatrics 2014;134(4):12441256. 51. Diedrich JT, Klein DA, Peipert JF. Long-acting reversible contraception in adolescents: A systematic review and meta-analysis. Am J Obstet Gynecol 2017;216(4):e1-e12. https://doi.org/10.1016/j.ajog.2016.12.024 52. O’Neill E, Tang J, Garrett JHD. Characteristics of Kenyan women in a prospective cohort study who continue using subdermal contraceptive implants at 12 months. Contraception 2014;89(3):204-208. https://doi.org/10.1016/j.contraception.2013.11.016 53. Steyn PS, Cordero JP, Gichangi P, et al. Participatory approaches involving community and HCPs in family planning/contraceptive information and service provision: A scoping review. Reprod Health 2016;13(1):88. 54. Higgins JA. Celebration meets caution: LARC’s boons, potential busts, and the benefits of a reproductive justice approach. Contraception 2014; 89(4):237-241. https://doi.org/10.1016/j.contra ception.2014.01.027 55. Ross L. A Primer on Reproductive Justice and Social Change. Berkeley, CA: SisterSong Women of Color Reproductive Health Collective, 2007. 56. World Health Organization. Ensuring Human Rights in the Provision of Contraceptive Information and Services Guidance and Recommendations. Geneva: WHO, 2014. 57. Newman K, Feldman-Jacobs C. Family Planning and Human Rights – What’s the Connection and Why is it Important. Policy Brief. Washington DC: Population Reference Bureau, 2015.

November 2017, Print edition

Go digital with Discovery | HealthID DrConnect Discovery Health brings you the very latest in digital health technology by significantly enhancing HealthID. The new HealthID DrConnect functionality is a new way for you to seamlessly connect with your patients and peers in a completely secure, confidential environment. You can answer questions from patients, connect with your peers on complex cases and conduct follow-up virtual consultations with your patients.

Join a growing community of doctors connecting anywhere, anytime Download the HealthID app from the App Store or visit www.discovery.co.za Discovery HealthID DrConnect is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.

GM_48752DHM_18/10/17_V3

CME

58. Department of Health. Sexual and Reproductive Health and Rights: Reviewing the Evidence Literature Review and Situation Analysis Undertaken to Inform Sexual and Reproductive Health and Rights: Fulfilling our Commitments. 2011 - 2021 and Beyond. Pretoria: DoH, 2011. 59. Department of Health. National Contraception Policy Guidelines Within a Reproductive Health Framework. Pretoria: DoH, 2001. 60. Lince-Deroche N, Pleaner M, Harries J, et al. Achieving Universal Access to Sexual and Reproductive Health Services: The Potential and Pitfalls for Contraceptive Services. South African Health Review 2016. Durban: Health Sytems Trust, 2016.

61. Patel RC, Morroni C, Scarsi KK, Sripipatana T, Kiarie J, Cohen CR. Concomitant contraceptive implant and efavirenz use in women living with HIV: Perspectives on current evidence and policy implications for family planning and HIV treatment guidelines. J Int AIDS Soc 2017;20:21396. https://doi.org/10.7448/ias.20.1.21396 62. Department of Health. National Contraception Clinical Guidelines. Pretoria: DoH, 2012.

Accepted 18 August 2017.

November 2017, Print edition

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

CME

Strengthening implant provision and acceptance in South Africa with the ‘Any woman, any place, any time’ approach: An essential step towards reducing unintended pregnancies H Rees,1 MB BChir, MA (Cantab), MRCGP, DCH, DRCOG; Y Pillay,2 PhD; S Mullick,1 MB ChB, MSc, MPH, PhD; M F Chersich,1 MB BCh, PhD 1 2

Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa National Department of Health, Pretoria, South Africa

Corresponding author: H Rees (hrees@wrhi.ac.za)

Progress in reducing unintended pregnancies in South Africa is slow. The implant, introduced in 2014, expanded the range of available longacting reversible contraceptives (LARCs) and held much promise. Uptake, however, has declined precipitously, in spite of its ‘unmatched effectiveness’ and high levels of satisfaction for most users. We propose policy and provider interventions to raise implant use, underscored by a ‘LARC-first’ approach. Contraceptive counselling should focus on the particular benefits of LARCs and methods be presented in order of effectiveness. Moreover, implants hold particular advantages for certain groups, especially adolescents and young women, in whom it is considered first-line contraception. Provision of immediate postpartum and post-abortion implants is safe and highly acceptable, yet remains under-utilised. Implant services at HIV and tuberculosis clinics are a key priority, as is inclusion of LARC provision within school health services. Implants could also be delivered by existing mobile outreach services, for example in sex worker programmes. Services could be built around nurses dedicated solely to providing implants, with other health workers receiving brief refresher training. Women who experience side-effects, especially abnormal bleeding, require timely interventions, following a standardised protocol, including use of medications. Encouraging return for side-effects, follow-up phone calls and home visits would raise continuation rates. Removal services require doctor support or designated nurses at specific centres. Limited access to removal services, health workers’ resistance or botched procedures will further undermine implant provision. Rapid implant demonstration projects in postpartum wards, schools, outreach services and by dedicated providers may rapidly advance the field. Together, the actions outlined here will ensure that the implant fulfils its potential and reinvigorates family planning services. S Afr Med J 2017;107(11):939-944. DOI:10.7196/SAMJ.2017.v107i11.12903

2014/2015 to only 50 000 in 2016/2017,[14] with declines noted in all provinces of the country (Fig. 1). Levels of uptake have been especially low in Mpumalanga, the Northern Cape and North West Province since the introduction of the implant. Similar concerns prevail around the copper IUD, which accounts for only 2% of all contraceptive use, 80 000

Headache[38]

40 000

20 000

hW est We ste rn Ca pe

Ca pe

No rt

ala ng a

po p

-Na tal

Lim

Kw aZ ulu

Sta te ute ng Ga

Fre e

Ea ste

Ca pe

Fig. 1. Total numbers of implant insertions for each province in South Africa from April 2014 to March 2017[14] (no data are available for the Eastern Cape, the Free State, North West, or the Western Cape for financial year 2015). (FY = financial year.)

Bleeding side-effects[23,38,39,81-85]

FY 2015 FY 2016 FY 2017

60 000 Implants, n

Despite the launch of a new national contraceptive policy in 2012 and the introduction of the implant contraceptive in 2014,[1] South Africa (SA) is making slow progress in reducing levels of unintended pregnancies, including among teenagers.[2] Implants and the intrauterine device (IUD), both referred to as long-acting reversible contraceptives (LARCs), have much greater effectiveness than short-acting alternatives.[3,4] Oral contraceptives, for example, have contraceptive failure rates as high as 20/100 woman-years[5] compared with a failure rate of 0.05% for the implant and 0.8% for the copper IUD.[4] Given the ‘unmatched effectiveness’[6] of implants and continuation rates of ~80% at 1 year in multiple assessments globally,[4,7,8] some proponents consider implants – alongside IUDs – to be ‘first-line’ contraceptives, and other methods as ‘second-tier’.[9] Indeed, professional bodies in the USA recommend that providers must emphasise that LARCs are ‘the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women’.[10,11] In SA, Implanon is currently used to provide pregnancy protection for 3 years, but increasingly evidence suggests that protection may extend to 5 years, even in women with a high body mass index.[12,13] Prolonged effectiveness would further improve Implanon’s convenience for women, and reduce removal procedures and costs of implant replacements. Despite the effectiveness and programmatic advantages of the implant, its promise has not been realised in SA. The number of implants inserted in the public sector has fallen from ~175 000 in

No change

November 2017, Print edition

Continuation rates all women (12 months)[23,37,40,82,83,86]

Absent, light, infrequent bleeding

None

Continue implant

Frequent, prolonged, and/or heavy bleeding

Intolerable

Mild Severe

Removal

Intolerable

CME

Table 1. ‘Any woman, any place, any time’ approach: Addressing the patient, system and provider barriers to implant initiation and continuation Target population groups Women attending family planning clinic, including firsttime users, women unsure about method, and women seeking renewal of short-acting method

Settings for implant provision Family planning clinics and primary healthcare clinics

Health workers Primary care nurses, dedicated LARC providers, and doctors (removals)

Adolescents and young women

Post-abortion women Special target populations, such as HIV-infected women, TB patients, sex workers

Schools, youth-friendly services, campus clinics and technical colleges Labour wards (demand generated in antenatal clinics) Termination-of-pregnancy wards Mobile outreaches HIV and TB clinics

Communities

Community settings, households

School health nurses, dedicated LARC providers Midwives (labour wards and antenatal clinics) Nurses Dedicated LARC providers, CHWs, and HIV lay counsellors CHWs, and HIV lay counsellors

Postpartum women

LARC = long-acting reversible contraceptive; CHW = community health worker; TB = tuberculosis.

mainly because of limited nurse training in insertion and suboptimal access in family planning clinics.[15] In addition, the longstanding question of whether depot medroxyprogesterone acetate (DMPA) increases women’s risk for HIV acquisition will soon be answered by the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study.[16] If a significant association is demonstrated, there may be a compelling reason to restrict the provision of injectables for women at high risk of HIV infection. Against this background, SA needs to redouble its efforts to improve contraceptive access for all women, especially to LARCs. This commentary therefore proposes a new approach for SA, described by Hathaway et al.,[17] centring on the concept of ‘Any woman, any place, any time’, which holds that women should have access to LARCs in a range of complementary settings. We outline the policy, systems and provider interventions required to support this approach (Table 1).[18]

Building the workforce for implant provision

A range of health worker cadres are required, including staff dedicated solely to LARC provision. In Zambia, retired midwives were placed at high-volume, public-sector facilities solely to provide LARCs. Only 18 of these facilities were able to insert >22 000 implants in 14 months, which is nearly half of the number inserted in all of SA in 2016/2017.[19] As dedicated providers have the necessary time and skills – and a mandate – they were able to generate demand, provide quality services and guide the work of other family planning staff.[19] Dedicated providers cannot function in isolation and require tightly ring-fenced time, sufficient clients, supplies and supervision to allow them to maintain competency, confidence and producti vity. [20] In many parts of sub-Saharan Africa, dedicated providers also deliver implant services through mobile outreaches, which can rapidly increase implant uptake.[8,21] Existing outreach services in SA, for example to schools and among groups such as female sex workers,[22] provide a solid platform for such services. Projects pilot ing provision of implants in outreach services and through dedicated providers are needed. While implant provision is built around nurses, doctors need to play a larger role, especially regarding removal procedures. Further more, in several settings in Africa and Asia, LARC services rely heavily on community health workers (CHWs).[23-25] They lead community-based distribution of the implant, visit users’ homes

and provide support for women experiencing side-effects. A study in rural Northern Nigeria, where CHWs were tasked with inserting implants, showed the importance of frequent supervisory visits for CHWs.[24] In the absence of such support, CHWs reverted to dispensing shorter-acting methods.[26] CHWs in SA, especially at ‘primary healthcare re-engineering’ sites,[27] and HIV lay counsellors – already adept at ‘task shifting’ – could play an important role in implant services through demand creation, conducting pre-insertion counselling around LARCs and providing follow-up support. Brief, carefully designed training can raise uptake and continuation of the implant. A cluster-randomised trial involving 40 clinics in the USA demonstrated the effectiveness of a half-day training intervention of healthcare workers. Following the training, twice as many women chose a LARC method and subsequent rates of unintended pregnancy were cut by 50% compared with controls.[28] Training in this and other instances have included orientation to tools such as procedural checklists, contraceptive effectiveness charts, clinical case discussions, practical training with anatomical models and audiovisual materials.[29] To be effective, however, training does need to be carefully planned and accompanied by other interventions to strengthen service delivery. In a study in Bangladesh, for example, training was largely ineffective, as health system weaknesses constrained the potential for service improvements.[30] SA data also indicate that training that is too short and does not include management of side-effects and removals, may be inadequate to support implant provision.[31,32]

Pre-insertion counselling and ongoing support

Adopt a ‘LARC first’ structured approach to contraceptive counsel ling. The content of contraceptive counselling heavily influences method selection, especially among younger women.[33-35] While it is important to avoid coercion and ensure patient-centred, shared decision-making, we contend that it is time for a more directive approach, one in which women are explicitly informed that LARCs constitute first-line contraception. In this approach, counselling is standardised and methods are presented in order from most to least effective.[36] Currently, it appears that during family planning counselling in SA, little attention is given to the relative effectiveness of different contraceptives, even though these can vary by as much as 100-fold.[4,32] Existing social media platforms, especially MomConnect and NurseConnect, have a key role to play in propagating messaging

November 2017, Print edition

CME

most women do not experience increased bleeding and the certainty of highly effective contraception may, in fact, increase sexual pleasure. A study in the USA showed that 35% of implant users reported an improved sex life, 48% reported no change and 17% reported a worsened sex life.[4,3] Actively follow-up implant users and strongly encourage them to return to the clinic for advice, reassurance, treatment of side-effects or implant removal, if desired. Women seldom return to the clinic to discuss problems encountered with the implant; instead, they rely on friends, the internet and social media to help them to decide whether to remove the implant.[44] Social media contain many useful, accurate resources, presenting the implant from a patient’s perspective, although admittedly alongside much misinformation.[45] In a trial in India, actively following up implant users through phone calls or home visits was able to raise continuation rates.[46] Calls, lasting 4 minutes on average, might be feasible in SA, given that women’s contact details are routinely collected at each clinic visit, although these details are often incomplete and subject to frequent changes.[47] Other studies examining active follow up had less promising findings, even though these were mostly in high-income countries and had weaker study designs.[48-50] Intervene as soon as possible when FY 2015as a problem. Often, bleeding is presented 2016 when women do FYreturn to the clinic for FY 2017 advice about side-effects, they are simply told to ‘persevere’ or ‘wait and see’;[44,51] yet, these encounters are critical, as they may be the final chance for supporting continuation of the method. The large majority of patients who present with problems subsequently remove the device. Supportive interventions at such visits appear to be especially effective at raising continuation among adolescents and young women.[52] Health workers require a protocol for managing abnormal

Ea ste rn

Ca pe Fre eS tat e Ga ute ng Kw aZ ulu -Na tal Lim po po Mp um ala ng No a rth ern Ca pe No rth We st We ste rn Ca pe

Implants, n

around ‘LARCs first’ and generating demand for these methods. Strategies targeting men are also required. ‘Anticipatory guidance’ before implant insertion can prepare women for sideeffects.[18] The key topic to discuss before implant insertion is potential bleeding changes and the acceptability to the client within her sociocultural and relationship context. This is important, as changes in uterine bleeding patterns, while generally not harmful, are to be expected with implant use. Even though rates vary across studies, generally, of 100 women who use Implanon, ~30 will have no bleeding at all or no change to their normal bleeding patterns, 30 will have lighter, less frequent bleeding than usual, 15 - 20 will report prolonged, heavy nuisance bleeding, and 5 - 15 will experience intolerable bleeding resulting in implant removal (Fig. 2).[37-39] Jadelle and a similar device, the Sino-implant, have fewer bleeding side-effects than Impla non.[13,37,40,41] Continuation rates were also better with Jadelle than Implanon in several studies,[37,41] but not in a multi-country randomised trial.[40] Women should be given written informa tion, providing further explanation of changes in bleeding patterns that could be anticipated and the possibilities of treatment for these.[42] While anticipatory guidance is likely to be useful, it 80is000clearly difficult to fully prepare women for the reality of 60 000 Such bleeding heavy or prolonged bleeding. patterns have substantial deleterious effects on a woman’s comfort, 40 on000costs of sanitary protection and on sexual relations. In a 000 study of SA women, 20considerably more married or cohabiting women removed 0 the implant owing to bleeding side-effects than those who were single or in casual relationships, suggesting that implants may be especially suited to the latter groups.[32] It is important, however, to consider the effects of the implant on overall sexual health, as

Frequent, prolonged, and/or heavy bleeding

Absent, light, infrequent bleeding

No change

Bleeding side-effects[23,38,39,81-85]

Intolerable

Mild Severe

Headache[38]

None

Continuation rates all women (12 months)[23,37,40,82,83,86]

Continue implant

Removal

Continuation rates adolescents and women <25 years (12 months)[7,57,87]

Continue implant

Removal

Intolerable

100

Fig. 2. Approximate continuation rates and likelihood of bleeding and headache side-effects. Rates of side-effects and of continuation vary between studies; the figures provided are indicative.

November 2017, Print edition

bleeding, which encompasses the routine use of appropriate medications, including long-term therapies. Medications can include non-steroidal anti-inflammatory drugs, such as ibuprofen and mefenamic acid, and hormonal drugs, such as combined oral contraceptives or ethinyl oestradiol.[53] Although health workers in SA commonly prescribe treatment for bleeding and headaches related to the implant, medi cation regimens vary considerably and a standardised approach is needed.[31,32] Health workers’ resistance to removals, or other failures in accessing removal services, will rapidly tarnish the implant’s image and potentially undermine the entire family planning programme. Service delivery capacity for removals is a problem in many places[54] and women often resort to private sector providers.[32] Opportunities for nurses to become skilled in implant removals were limited in the early years after implant introduction when demand for removals was low. In SA, this resulted in a number of botched removals or repeated unsuccessful attempts at removal, fuelling negative media and community coverage for the implant.[55] Selected family planning nurses and doctors must be trained to perform removals and be counselled that they only encounter women with side-effects, which may give them a falsely negative impression of the method. The majority of women find the method highly satisfactory and therefore don’t interface with the system until time of removal. In cases of difficult removals, either anticipated or after a single failed attempt at removal, nurses must immediately refer for expert support, rather than persisting in their efforts.

Targeting of population groups

Although suitable for ‘any woman’, the implant has been most successfully targe ted at specific populations, most especially youth, first-time contraceptive users, and postpartum and post-abortion women. Making implants and other LARCS accessible for these groups must be considered a major priority for family planning in SA, signalling a step change for the national programme. Conducting a few rapid demon stration projects may provide the impetus needed for widespread implementation. LARCs should be first-line contra ceptive options for adolescents and young women. Counselling focused on the parti cular efficacy and benefits of LARCs is able to lower the rates of pregnancy and abortion in adolescents and young women.[56] In one large study, two-thirds of youth were still using a LARC after 2 years, compared with

CME

only one-third of those who had selected a non-LARC method. In most studies, rates of implant continuation in young women were higher than in older women (Fig. 2).[7,57] In Kenya, when implants were made available to young women seeking family planning, a quarter selected the method.[58] In SA, such advances may be hampered by healthcare providers’ opinions, which are often divergent from laws governing contraceptive access among adolescents.[59] Value judgements about sexual activity among youth may even lead to girls being denied contraceptives. The ongoing refusal to provide contraceptives in schools in the face of rising pregnancy rates among learners, can no longer be justified from a public health and gender equity perspective, and is at odds with World Health Organization guidance on safeguarding human rights in the provision of contraceptive services for young women.[60] A national policy recommending LARCs as first-line contraception and in-school provision of these services, either through provision by visiting nurses or mobile clinics, would go a long way to overcoming these access barriers. Postpartum and post-abortion family planning services represent a critical pregnancy prevention tool that remains surpri singly under-utilised. Short inter-pregnancy intervals are associated with negative maternal and infant health outcomes, and an interval of at least 2 years between pregnancies is recommended.[61] More than 10 trials, including one in sub-Saharan Africa,[62] have examined the safety, uptake and continuation rates of implant provision in the immediate postpartum period.[63] Implants inserted within 48 hours postpartum appear not to affect lactation, growth, and neonatal and infant development.[64-66] In a trial in the USA,[66] as many as 90% of adolescents took up the offer of an implant after delivery, and uptake rates were also high in Uganda[62] and Kenya.[67] For postpartum LARC services to be successful, however, robust linkages are required between providers working in family planning, antenatal and labour wards. Counselling about postpartum LARC placement needs to begin during antenatal care. Attention is required to ensure that linkages between family planning providers and labour wards are robust enough to avoid undue delays in implant insertion, noting that many women are discharged within 24 hours of childbirth. If services are not streamlined, women may be instructed to return for implant insertion at their 6-week postpartum visit, which for many may mean that insertion will not occur.[63] Most patients who have had an abortion wish to avoid a subsequent pregnancy and strongly desire a post-abortion contraceptive method.[68] LARC use among these women appears more effective than short-acting contraception in reducing repeat pregnancies and abortions.[69,70] In a multi-country trial, insertion of the implant immediately post abortion led to higher LARC use and reduced repeat pregnancies compared with insertion at a planned follow-up visit.[71] Also, in a study in Ethiopia, implant insertion immediately post abortion resulted in >80% of women leaving the facility with a contraceptive method compared with 58% before the services began.[72] LARC use rose from 2% to 55%. Provision of the implant at HIV and tuberculosis clinics, including for women taking efavirenz, is a key priority. Current approaches to family planning service provision in HIV treatment programmes have had limited success in reducing unintended pregnancies among HIV-infected women. Women receiving antiretroviral treatment have frequent contact with health services, providing seve ral opportunities for contraceptive provision. Reducing unintended pregnancies in these women would offer them considerable benefits, but also assist in reducing the number of HIV-infected children. In one study, however, in rural Mpumalanga, only a quarter of HIVinfected women had discussed family planning with their providers.[73]

There are substantial drug interactions between efavirenz and Implanon, considerably reducing drug levels of etonogestrel, the active drug in Implanon.[74-76] Interactions between efavirenz and Jadelle appear even more pronounced than with Implanon.[77,78] Women using an implant, who are also taking efavirenz, have higher pregnancy rates than those taking other antiretrovirals. The higher adherence to the implant, however, when compared with shortacting methods including injectable progestins,[79,80] means that despite this drug interaction, the implant remains highly effective in these women – more so than short-acting alternatives. Available data therefore do not support limiting access to the implant in women taking efavirenz.[75] Moreover, the use of efavirenz is likely to be phased out over time, alleviating many of these concerns.

Conclusions

The long-standing approach of prioritising contraceptive provision through family planning clinics may well account for the slow progress made in reducing unintended pregnancies in SA, including among adolescent girls. Making LARCs available in postpartum and postabortion wards, schools, and HIV and tuberculosis clinics, may help make considerable headway. At each contact with the health system, women of reproductive age should be asked about their fertility intentions and linked with LARC and other contraceptive services, as required. LARCs should be considered as first-line contraception for adolescents, young women and first-time contraceptive users; these groups should be actively targeted in schools and other services. The method may also be especially suitable for women in casual relationships or those who are single. Also, we recommend that demonstration projects be established, where nurses are recruited to work solely to provide LARCs and support implant provision more generally, especially in clinical outreach services. With additional training, existing lay healthcare workers could serve as advocates for LARCs and support their ongoing use once selected. Given the varying side-effects profile of implant devices, alternatives to Implanon might be considered, such as the Sino-implant. The clinical management of implant users needs to be improved and women should be actively followed up and encouraged to return, should bleeding patterns or other side-effects become a problem. When a woman does seek advice, the opportunity must be capitalised upon to allow early medical management and/or implant removal, hence ensuring her ongoing confidence in services and in the use of the implant. Women who have difficulties accessing removal services or encounter health worker resistance to removal may understandably become resentful, stoking rumours and distrust in the method and in family planning services more generally.[54] Responsive, quality removal services are required, performed by the appropriate level of health worker, with supportive expert referral when required. Even though the contraceptive efficacy of the implant is reduced in women taking efavirenz, the implant may still be more effective than alternative methods, and access to implants should not be restricted for women taking efavirenz, provided adequate counselling is offered. Together, the set of concerted actions outlined in this article could ensure that the implant fulfils its potential contribution to reducing unintended pregnancies in SA. Acknowledgements. Candy Day, Health Systems Trust, for providing updated District Health Information System (DHIS) data. Author contributions. HR and MFC wrote the initial draft. YP and SM provided critical inputs on subsequent iterations. All authors cleared the final article for submission.

November 2017, Print edition

CME

Funding. None. Conflicts of interest. None. 1. National Department of Health. National Contraception and Fertility Planning Policy and Service Delivery Guidelines: A Companion to the National Contraception Clinical Guidelines. Pretoria: NDoH, 2012. 2. National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and Inner City Fund (ICF). South Africa Demographic and Health Survey 2016: Key Indicators. 2017. http://www.statssa.gov.za/publications/Report%2003-00-09/Report%200300-092016.pdf (accessed 3 September 2017). 3. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366(21):1998-2007. https://doi.org/10.1056/NEJMoa1110855 4. Trussell J. Contraceptive efficacy. In: Hatcher RATJ, Nelson AL, Cates W, Kowal D, Policar M, eds. Contraceptive Technology. 20th rev. ed. New York: Ardent Media, 2011. 5. Moodley J, Naidoo S, Wand H, Ramjee G. Contraception use and impact on pregnancy prevention in women participating in an HIV prevention trial in South Africa. J Fam Plann Reprod Health Care 2016;42(1):5-11. https://doi.org/10.1136/jfprhc-2014-101100 6. Jacobstein R, Stanley H. Contraceptive implants: Providing better choice to meet growing family planning demand. Glob Health Sci Pract 2013;1(1):11-17. https://doi.org/10.9745/GHSPD-12-00003 7. Chiles DP, Roberts TA, Klein DA. Initiation and continuation of long-acting reversible contraception in the United States military healthcare system. Am J Obstet Gynecol 2016;215(3):e321-e329. https:// doi.org/10.1016/j.ajog.2016.03.027 8. Duvall S, Thurston S, Weinberger M, Nuccio O, Fuchs-Montgomery N. Scaling up delivery of contraceptive implants in sub-Saharan Africa: Operational experiences of Marie Stopes International. Glob Health Sci Pract 2014;2(1):72-92. https://doi.org/10.9745/GHSP-D-13-00116 9. O’Neil-Callahan M, Peipert JF, Zhao Q, Madden T, Secura G. Twenty-four-month continuation of reversible contraception. Obstet Gynecol 2013;122(5):1083-1091. https://doi.org/10.1097/AOG.0b013e3182a91f45 10. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 539. Adolescents and long-acting reversible contraception: Implants and intrauterine devices. 2012. www.acog.org/ Resources_And_Publications/Committee_Opinions/Committee_on_Adolescent_Health_Care/ Adolescents_and_Long-Acting_Reversible_Contraception (accessed 3 October 2017). 11. Committee on Adolescence. Contraception for adolescents. Pediatrics 2014;134(4):e1244-e1256. https:// doi.org/10.1542/peds.2014-2299 12. McNicholas C, Maddipati R, Zhao Q, Swor E, Peipert JF. Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the US Food and Drug Administration-approved duration. Obstet Gynecol 2015;125(3):599-604. https://doi.org/10.1097/aog.0000000000000690 13. Ali M, Akin A, Bahamondes L, et al. Extended use up to 5 years of the etonogestrel-releasing subdermal contraceptive implant: Comparison to levonorgestrel-releasing subdermal implant. Hum Reprod 2016;31(11):2491-2498. https://doi.org/10.1093/humrep/dew222 14. Massyn N, Peer N, Padarath A, Day C, eds. District Health Barometer 2016/17. Durban: Health Systems Trust, 2017. 15. Lince-Deroche N, Pleaner M, Morroni C, et al. Achieving universal access to sexual and reproductive health services: The potential and pitfalls for contraceptive services in South Africa. South African Health Review 2016;2016(1):95-108. 16. ECHO Consortium. Evidence for Contraceptive Options and HIV Outcomes (ECHO) study. 2017. http://echo-consortium.com/ (accessed 4 September 2017). 17. Hathaway M, Torres L, Vollett-Krech J, Wohltjen H. Increasing LARC utilization: Any woman, any place, any time. Clin Obstet Gynecol 2014;57(4):718-730. https://doi.org/10.1097/grf.0000000000000071 18. Jacobstein R, Stanley H. Contraceptive implants: Providing better choice to meet growing family planning demand. Glob Health Sci Pract 2013;1(1):11-17. https://doi.org/10.9745/GHSP-D-12-00003 19. Neukom J, Chilambwe J, Mkandawire J, Mbewe RK, Hubacher D. Dedicated providers of long-acting reversible contraception: New approach in Zambia. Contraception 2011;83(5):447-452. https://doi. org/10.1016/j.contraception.2010.08.021 20. Schaefer L. Task sharing implant insertion by community health workers: Not just can it work, but how might it work practically and with impact in the real world. Glob Health Sci Pract 2015;3(3):327-329. https://doi.org/10.9745/ghsp-d-15-00230 21. Duvall S, Thurston S, Weinberger M, Nuccio O, Fuchs-Montgomery N. Scaling up delivery of contraceptive implants in sub-Saharan Africa: Operational experiences of Marie Stopes International. Glob Health Sci Pract 2014;2(1):72-92. https://doi.org/10.9745/GHSP-D-13-00116 22. Slabbert M, Venter F, Gay C, et al. Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes. BMC Publ Health 2017;17(Suppl 3):442. https://doi.org/10.1186/s12889-017-4346-0 23. Gupta S, Mola G, Ramsay P, et al. Twelve month follow-up of a contraceptive implant outreach service in rural Papua New Guinea. Aust N Z J Obstet Gynaecol 2017;57(2):213-218. https://doi.org/10.1111/ ajo.12596 24. Charyeva Z, Oguntunde O, Orobaton N, et al. Task shifting provision of contraceptive implants to community health extension workers: Results of operations research in Northern Nigeria. Glob Health Sci Pract 2015;3(3):382-394. https://doi.org/10.9745/ghsp-d-15-00129 25. Asnake M, Henry EG, Tilahun Y, Oliveras E. Addressing unmet need for long-acting family planning in Ethiopia: Uptake of single-rod progestogen contraceptive implants (Implanon) and characteristics of users. Int J Gynaecol Obstet 2013;123(Suppl 1):e29-e32. https://doi.org/10.1016/j.ijgo.2013.07.003 26. Weaver EH, Frankenberg E, Fried BJ, et al. Effect of village midwife program on contraceptive prevalence and method choice in Indonesia. Stud Fam Plann 2013;44(4):389-409. https://doi.org/10.1111/j.17284465.2013.00366.x 27. Austin-Evelyn K, Rabkin M, Macheka T, et al. Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa. PLoS ONE 2017;12(3):e0173863. https://doi. org/10.1371/journal.pone.0173863 28. Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with longacting reversible contraception: A cluster randomised trial. Lancet 2015;386(9993):562-568. https://doi. org/10.1016/s0140-6736(14)62460-0 29. Gibbs SE, Rocca CH, Bednarek P, et al. Long-acting reversible contraception counseling and use for older adolescents and nulliparous women. J Adolesc Health 2016;59(6):703-709. https://doi.org/10.1016/j. jadohealth.2016.07.018 30. Rahman M, Haider MM, Curtis SL, Lance PM. The Mayer Hashi large-scale program to increase use of long-acting reversible contraceptives and permanent methods in Bangladesh: Explaining the disappointing results. An outcome and process evaluation. Glob Health Sci Pract 2016;4(Suppl 2):S122-S139. https://doi. org/10.9745/ghsp-d-15-00313 31. Adeagbo OA, Mullick S, Pillay D, et al. Uptake and early removals of Implanon NXT in South Africa: Perceptions and attitudes of healthcare workers. S Afr Med J 2017;107(10):822-826. https://doi.org/10.7196/ SAMJ.2017.v107i10.12821 32. Pillay D, Chersich MF, Morroni C, et al. User perspectives on Implanon NXT in South Africa: A survey of 12 public-sector facilities. S Afr Med J 2017;107(10):815-821. https://doi.org/10.7196/SAMJ.2017. v107i10.12833

33. Riney S, O’Shea B, Forde A. Etonogestrel implant as a contraceptive choice; patient acceptability and adverse effect profile in a general practice setting. Ir Med J 2009;102(1):24-25. 34. Whitaker AK, Quinn MT, Munroe E, et al. A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial. Patient Educ Couns 2016;99(10):1663-1669. https://doi.org/10.1016/j.pec.2016.05.011 35. Minnis AM, Mavedzenge SN, Luecke E, Dehlendorf C. Provider counseling to young women seeking family planning services. Perspect Sex Reprod Health 2014;46(4):223-231. https://doi.org/10.1363/46e1414 36. Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception 2013;88(2):243-249. https://doi.org/10.1016/j. contraception.2012.07.015 37. Short M, Dallay D, Omokanye S, Stauch K, Inki P. Acceptability of long-acting, progestin-only contraception in Europe: A two-year prospective, non-interventional study. Eur J Contracept Reprod Health Care 2014;19(1):29-38. https://doi.org/10.3109/13625187.2013.862230 38. Blumenthal PD, Gemzell-Danielsson K, Marintcheva-Petrova M. Tolerability and clinical safety of Implanon®. Eur J Contracept Reprod Health Care 2008;13(Suppl1):29-36. https://doi. org/10.1080/13625180801960012 39. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): Results from 11 international clinical trials. Fertil Steril 2009;91(5):1646-1653. https://doi.org/10.1016/j.fertnstert.2008.02.140 40. Bahamondes L, Brache V, Meirik O, et al. A 3-year multicentre randomized controlled trial of etonogestreland levonorgestrel-releasing contraceptive implants, with non-randomized matched copper-intrauterine device controls. Hum Reprod 2015;30(11):2527-2538. https://doi.org/10.1093/humrep/dev221 41. Berenson AB, Tan A, Hirth JM. Complications and continuation rates associated with 2 types of long-acting contraception. Am J Obstet Gynecol 2015;212(6):e761-e768. https://doi.org/10.1016/j.ajog.2014.12.028 42. Modesto W, Bahamondes MV, Bahamondes L. A randomized clinical trial of the effect of intensive versus non-intensive counselling on discontinuation rates due to bleeding disturbances of three long-acting reversible contraceptives. Hum Reprod 2014;29(7):1393-1399. https://doi.org/10.1093/humrep/deu089 43. Higgins JA, Sanders JN, Palta M, Turok DK. Women’s sexual function, satisfaction, and perceptions after starting long-acting reversible contraceptives. Obstet Gynecol 2016;128(5):1143-1151. https://doi. org/10.1097/aog.0000000000001655 44. Lunde B, Littman L, Stimmel S, et al. ‘Just wear dark underpants mainly’: Learning from adolescents’ and young adults’ experiences with early discontinuation of the contraceptive implant. J Pediatr Adolesc Gynecol 2017;30(3):395-399. https://doi.org/10.1016/j.jpag.2016.12.006 45. Paul J, Boraas CM, Duvet M, Chang JC. YouTube and the single-rod contraceptive implant: A content analysis. J Fam Plann Reprod Health Care 2017;43(3):195-200. https://doi.org/10.1136/ jfprhc-2016-101593 46. Hameed W, Azmat SK, Ali M, et al. Comparing effectiveness of active and passive client follow-up approaches in sustaining the continued use of long acting reversible contraceptives (LARC) in rural Punjab: A multicentre, non-inferiority trial. PLoS ONE 2016;11(9):e0160683. https://doi.org/10.1371/ journal.pone.0160683 47. Pillay D, Morroni C, Pleaner M, et al. Gaps in monitoring systems for Implanon NXT services in South Africa: An assessment of 12 facilities in two districts. S Afr Med J 2017;107(10):827-831. https://doi. org/10.7196/SAMJ.2017.v107i10.12822 48. Steenland MW, Zapata LB, Brahmi D, Marchbanks PA, Curtis KM. The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use. Contraception 2013;87(5):625-630. https://doi.org/10.1016/j.contraception.2012.09.018 49. Neuteboom K, de Kroon CD, Dersjant-Roorda M, Jansen FW. Follow-up visits after IUD-insertion: Sense or nonsense? A technology assessment study to analyze the effectiveness of follow-up visits after IUD insertion. Contraception 2003;68(2):101-104. 50. Kirby D, Raine T, Thrush G, et al. Impact of an intervention to improve contraceptive use through followup phone calls to female adolescent clinic patients. Perspect Sex Reprod Health 2010;42(4):251-257. https://doi.org/10.1363/4225110 51. Dickson J, Hoggart L, Newton VL. Unanticipated bleeding with the etonogestrel implant: Advice and therapeutic interventions. J Fam Plann Reprod Health Care 2014;40(3):158-160. https://doi.org/10.1136/ jfprhc-2013-100817 52. Ravi A, Prine L, deFiebre G, Rubin SE. Beyond the surface: Care seeking among patients initiating contraceptive implant in an urban federally qualified health center network. J Prim Care Commun Health 2017;8(1):20-257. https://doi.org/10.1177/2150131916666011 53. World Health Organization. Selected Practice Recommendations for Contraceptive Use. 3rd ed. Geneva: WHO, 2016. 54. Kalmuss D, Davidson AR, Cushman LF, Heartwell S, Rulin M. Determinants of early implant discontinuation among low-income women. Fam Plann Perspect 1996;28(6):256-260. https://doi.org/ 10.2307/2136054 55. Skosana I. Birth control implant needs a shot in the arm. Mail and Guardian, 29 May 2015. 56. Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014;371(14):1316-1323. https://doi.org/10.1056/NEJMoa1400506 57. Diedrich JT, Klein DA, Peipert JF. Long-acting reversible contraception in adolescents: A systematic review and meta-analysis. Am J Obstet Gynecol 2017;216(4):e361-e364;e312. https://doi.org/10.1016/j. ajog.2016.12.024 58. Hubacher D, Olawo A, Manduku C, Kiarie J. Factors associated with uptake of subdermal contraceptive implants in a young Kenyan population. Contraception 2011;84(4):413-417. https://doi.org/1016/j. contraception.2011.02.007 59. Holt K, Lince N, Hargey A, et al. Assessment of service availability and health care workers’ opinions about young women’s sexual and reproductive health in Soweto, South Africa. Afr J Reprod Health 2012;16(2):283-293. 60. Hoopes AJ, Chandra-Mouli V, Steyn P, Shilubane T, Pleaner M. An analysis of adolescent content in South Africa’s contraception policy using a human rights framework. J Adolesc Health 2015;57(6):617623. https://doi.org/10.1016/j.jadohealth.2015.08.012 61. World Health Organization. Report of a WHO Technical Consultation on Birth Spacing. Geneva: WHO, 2005. 62. Averbach S, Kakaire O, Kayiga H, et al. Immediate versus delayed postpartum use of levonorgestrel contraceptive implants: A randomized controlled trial in Uganda. Am J Obstet Gynecol 2017 (in press). https://doi.org/10.1016/j.ajog.2017.06.005 63. Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M. Immediate versus delayed postpartum insertion of contraceptive implant for contraception. Cochrane Database Syst Rev 2017;(4):CD011913. https://doi.org/10.1002/14651858.CD011913.pub2 64. Braga GC, Ferriolli E, Quintana SM, et al. Immediate postpartum initiation of etonogestrel-releasing implant: A randomized controlled trial on breastfeeding impact. Contraception 2015;92(6):536-542. https://doi.org/10.1016/j.contraception.2015.07.009 65. Carmo L, Braga GC, Ferriani RA, Quintana SM, Vieira CS. Timing of etonogestrel-releasing implants and growth of breastfed infants: A randomized controlled trial. Obstet Gynecol 2017;130(1):100-107. https:// doi.org/10.1097/aog.0000000000002092 66. Bryant AG, Bauer AE, Stuart GS, et al. Etonogestrel-releasing contraceptive implant for postpartum adolescents: A randomized controlled trial. J Pediatr Adolesc Gynecol 2017;30(3):389-394. https://doi. org/10.1016/j.jpag.2016.08.003

November 2017, Print edition

Advertorial

Genesis Pharmaceuticals is here... Ditaba Mohapi is the Founding Member and CEO of Genesis Pharmaceuticals. He was born and bred in the small and rural town of Schweizer-Reneke, which is situated in the North West Province. His Dream Goal is to build and run a well-resourced, world-class manufacturing plant for pharmaceutical products right here in South Africa. He says that it is about time that this country, which has the required infrastructure, skills and competencies, take its rightful place in the closely guarded, global pharmaceutical industry.

Since its establishment in April 2011, Genesis Pharmaceuticals has grown in leaps and bounds in its pursuit for affordable and accessible medical, surgical and pharmaceutical supplies for all, especially for the poorest of the poor, across the sparsely populated North West Province, as well as other rural communities across the country and the continent. The company is duly registered with the Medical Control Council of South Africa (MCCSA) and the South African Pharmacy Council (SAPC). All of Genesis’s products are FDA, CE and ISO certified, with some certified and carrying the SABS labelling. The company also has long standing and meaningful relationships with reputable international manufacturers such as Comed Chemicals in India, and other global suppliers who are GMP and WHO recognised and accredited. Genesis Pharmaceuticals (Pty) Ltd is the brainchild of one of our own, the enthusiastic, entrepreneurial and visionary Ditaba Mohapi, who holds a Bachelor of Science Degree (with specialisation in Chemistry) from North West University (Mahikeng Campus), and an Honours Degree in the same field, from the University of Witwatersrand. He also has a Marketing Diploma from the University of South Africa. Ditaba’s scholastic credentials are expediently complemented by the vast experience he has gathered from working for the government, as well as a number of global pharmaceutical companies operating in South Africa. His global exposure have seen him visit countries such as India, China and Brazil, where his appreciation for international trade, industry standards and business practices were moulded and honed. Given his industrious passion for Good Pharmacy Practice (GPP), as

outlined in the South African Pharmacy Council Regulations, his end-to-end understanding of the pharmaceutical industry, as well as the meaningful support from his wife Dr. Masego Mohapi, who is a practicing medical doctor, it was not long before his steadfast desire for a “One Stop” Pharmaceutical Company prompted him to leave the corporate world’s comfort zone and venture into business, the business of making affordable pharmaceutical products readily accessible to all South Africans, and eventually to all the people of the African Continent. It was for this particular purpose that Genesis Pharmaceuticals (Pty) Ltd was conceived, birthed and grown. From its establishment to date the company remains a 100% black owned company. Genesis Pharmaceuticals supplies a wide range of quality and type approved Generics, Supplementary Medicines, Veterinary Medicines, Medical and Laboratory Equipment, Rapid Diagnostic Test Kits, Mortuary Products, Hygiene Products, Diapers and other Disposables, to mention but a few of its affordable basket of products and services. In the upper league of research and mastery, the company has chosen to focus on the fight against the dreaded cancer pandemic, and thus its niche market in top end oncology products. Genesis Pharmaceuticals is not just here for profits, but more importantly for a purpose, for people and for the planet (Quadruple Bottom-line). While most of the long established pharmaceutical companies are conveniently based in the country’s aﬄuent cities and metros, Genesis’s Head Office and Main Warehouse are strategically situated in Ditaba’s rural home town of Schweizer-Reneke, in the North West

Province, thus bringing the company closer to Dr Ruth Segomotsi Mompati District Municipality, while keeping it fairly accessible to the other three District Municipalities in the Province (Ngaka Modiri Molema, Dr Kenneth Kaunda and Bojanala Platinum District Municipalities). To this extent the company brought home the much needed jobs and expertise for the unemployed and the youth. The warehouse is also in close proximity with the Northern Cape Province, where its products and services have already proven to be of significant value and help. Moving closer to people in the cities and metros, Genesis has its first Distribution Outlet and Satellite Office right in the heart of Johannesburg, at the easy to locate Prism Business Park in Fourways. The company is planning to roll out more offices and distribution points across the country, and it reckons it’s only a matter of time before its affordable, quality products are accessible to all South Africans. To this extent, Genesis has a comprehensive logistics and distribution network to make its products seamlessly accessible to almost all of the Medical Practitioners, Healthcare Providers and Research Institutions across the country. In addition to the above mentioned range of pharmaceutical products, and in response to the need to cascade desirable skills and competencies in this highly specialised industry, Genesis Pharmaceuticals has now established a sister company, Genesis Pharmaceuticals Academy, and this well-received initiative focuses on providing basic to advanced training for Pharmacist Assistants, Healthcare Workers, Mortuary Assistants, Domestic Medical Waste Management as well as Dispensing Courses for Doctors and Nurses. Indeed Genesis Pharmaceuticals is here… to make a difference. When asked about his long term vision, this is what Mr. Mohapi had to say “Our medium to long term goal is to build a well-resourced, world-class manufacturing plant for pharmaceutical products right here in South Africa. This is our Strategic Intent. Furthermore, my personal Dream Goal is to see our two sons, Lereko (9) and Reaorata (2) having the liberty to settle in any part of our country, urban or rural, knowing that Genesis Pharmaceuticals is just around the corner for them and the communities they reside in, and therefore will not have to worry about costly and inaccessible pharmaceutical products. This is the family’s shared dream. This is our Challenge and our Pursuit.” Indeed, Genesis Pharmaceuticals is here to make a difference… and it is only through the conscious support of various stakeholders in the pharmaceutical and medical

industries that this noble course can be nourished, and its dreams can be brought to fruition. For more information on Genesis Pharmaceuticals, Please: • contact their office at: +27 (0)87 813 0335 or +27 (0)74 288 9400 • or mail them at: info@genesispharma.co.za or ditaba. mohapi@genesispharma.co.za • or visit their website at: www.genesispharma.co.za

From right: Mr Ditaba Mohapi, CEO of Genesis Pharmaceuticals, with the Managing Director of Comed Chemicals, Mr. Sh JS Sethi and Dr. Magome Masike, the MEC for Health in the North West Province.

CME

67. Shabiby MM, Karanja JG, Odawa F, et al. Factors influencing uptake of contraceptive implants in the immediate postpartum period among HIV infected and uninfected women at two Kenyan District Hospitals. BMC Womens Health 2015;15:62. https://doi.org/10.1186/s12905-015-0222-1 68. Kavanaugh ML, Carlin EE, Jones RK. Patients’ attitudes and experiences related to receiving contraception during abortion care. Contraception 2011;84(6):585-593. https://doi.org/10.1016/j. contraception.2011.03.009 69. Cameron ST, Glasier A, Chen ZE, et al. Effect of contraception provided at termination of pregnancy and incidence of subsequent termination of pregnancy. Br J Obstet Gynaecol 2012;119(9):1074-1080. https://doi.org/10.1111/j.1471-0528.2012.03407.x 70. Hofmeyr GJ, Singata-Madliki M, Lawrie TA, Bergel E, Temmerman M. Effects of the copper intrauterine device versus injectable progestin contraception on pregnancy rates and method discontinuation among women attending termination of pregnancy services in South Africa: A pragmatic randomized controlled trial. Reprod Health 2016;13:42. https://doi.org/10.1186/s12978-016-0153-9 71. Hognert H, Kopp Kallner H, Cameron S, et al. Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion – a randomized controlled equivalence trial. Hum Reprod 2016;31(11):2484-2490. https://doi.org/10.1093/humrep/dew238 72. Samuel M, Fetters T, Desta D. Strengthening postabortion family planning services in Ethiopia: Expanding contraceptive choice and improving access to long-acting reversible contraception. Glob Health Sci Pract 2016;4(Suppl 2):S60-S72. https://doi.org/10.9745/ghsp-d-15-00301 73. Rodriguez VJ, Cook RR, Weiss SM, Peltzer K, Jones DL. Psychosocial correlates of patient-provider family planning discussions among HIV-infected pregnant women in South Africa. Open Access J Contracept 2017;8:25-33. https://doi.org/10.2147/oajc.s134124 74. Chappell CA, Lamorde M, Nakalema S, et al. Efavirenz decreases etonogestrel exposure: A pharmacokinetic evaluation of implantable contraception with antiretroviral therapy. AIDS 2017;31(14):1956-1972. https:// doi.org/10.1097/qad.0000000000001591 75. Nanda K, Stuart GS, Robinson J, et al. Drug interactions between hormonal contraceptives and antiretrovirals. AIDS 2017;31(7):917-952. https://doi.org/10.1097/QAD.0000000000001392 76. Patel RC, Morroni C, Scarsi KK, et al. Concomitant contraceptive implant and efavirenz use in women living with HIV: Perspectives on current evidence and policy implications for family planning and HIV treatment guidelines. J Int AIDS Soc 2017;20(1):1-6. https://doi.org/10.7448/IAS.20.1.21396 77. Perry SH, Swamy P, Preidis GA, et al. Implementing the Jadelle implant for women living with HIV in a resource-limited setting: Concerns for drug interactions leading to unintended pregnancies. AIDS 2014;28(5):791-793. https://doi.org/10.1097/qad.0000000000000177

78. Scarsi KK, Darin KM, Nakalema S, et al. Unintended pregnancies observed with combined use of the levonorgestrel contraceptive implant and efavirenz-based antiretroviral therapy: A threearm pharmacokinetic evaluation over 48 weeks. Clin Infect Dis 2016;62(6):675-682. https://doi. org/10.1093/cid/civ1001 79. Pyra M, Heffron R, Mugo NR, et al. Effectiveness of hormonal contraception in HIV-infected women using antiretroviral therapy. AIDS 2015;29(17):2353-2359. https://doi.org/10.1097/QAD.0000000000000827 80. Patel RC, Onono M, Gandhi M, et al. Pregnancy rates in HIV-positive women using contraceptives and efavirenz-based or nevirapine-based antiretroviral therapy in Kenya: A retrospective cohort study. Lancet HIV 2015;2(11):e474-e482. https://doi.org/10.1016/S2352-3018(15)00184-8 81. Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon® on menstrual bleeding patterns. Eur J Contracept Reprod Health Care 2008;13(Suppl 1):13-28. https://doi. org/10.1080/13625180801959931 82. Ovre-Eide V, Skjeldestad FE. Use pattern for contraceptive implants in Norway. Acta Obstet Gynecol Scand 2016:95(11):1244-1250. https://doi.org/10.1111/aogs.13002 83. Roke C, Roberts H, Whitehead A. New Zealand women’s experience during their first year of Jadelle® contraceptive implant. J Prim Health Care 2016;8(1):13-19. https://doi.org/10.1071/hc15040 84. Diedrich JT, Desai S, Zhao Q, et al. Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction. Am J Obstet Gynecol 2015;212(1):e51-e58. https://doi.org/10.1016/j.ajog.2014.07.025 85. Casey PM, Long ME, Marnach ML, Bury JE. Bleeding related to etonogestrel subdermal implant in a US population. Contraception 2011;83(5):426-430. https://doi.org/10.1016/j.contraception.2010.09.012 86. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011;117(5):1105-1113. https://doi.org/10.1097/AOG.0b013e31821188ad 87. Abraham M, Zhao Q, Peipert JF. Young age, nulliparity, and continuation of long-acting reversible contraceptive methods. Obstet Gynecol 2015;126(4):823-829. https://doi.org/10.1097/ AOG.0000000000001036

Accepted 3 October 2017.

November 2017, Print edition

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

IN PRACTICE

ISSUES IN MEDICINE

The African Hospitalist Fellowship A D Daniels,1 MB ChB, FCPaed; H Buys,2 MB ChB, MRCP, FCPaed, MSc; R Dunkley,3 MB ChB, FCPaed; J M Wilmshurst,2 MB BS, MRCP, FCPaed, MD Neonatology Fellow, Royal Children’s Hospital, Melbourne, Australia African Paediatric Fellowship Program, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa 3 Ambulatory and Emergency Division, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa 1 2

Corresponding author: J M Wilmshurst (jo.wilmshurst@uct.ac.za)

The African Paediatric Fellowship Programme is rolling out a training course for newly qualified paediatricians to equip them with the leadership skills to function in complex general paediatric settings. The care of children in Africa carries its own unique demands, from the layering effects of multiple conditions through to establishing and sustaining services under severe resource constraints. This novel training concept aims to strengthen confidence and knowledge in areas that are not priorities during standard general paediatric training. The skills gained are considered of great relevance in assisting general paediatricians to achieve their full potential in their careers. S Afr Med J 2017;107(11):945-947. DOI:10.7196/SAMJ.2017.v107i11.12718

The dilemma following completion of general paediatrics training

The prospect of seeking a career after completing the 4 years of registrar training in general paediatrics is an increasing cause of anxiety for newly qualified specialists in South Africa (SA). In most regions, the prospects for employment are limited. Options include appointment to one of the few consultant positions in state hospitals, working in the private sector, or continuing to train in a subspecialty. Many may struggle to find regular employment and resort to locum work, which is not necessarily at specialist level. This could include overnight on-site calls, and other work well below a specialist level of experience. Subspecialty training positions may be undertaken as a means to maintain a further 2 - 3 years of full-time employment and/ or to increase the likelihood of successfully securing a future statesector consultant post in an increasingly competitive environment. It could be argued that there is a greater need for confident and experienced generalists to establish and run units, wards and services across all levels of care. This is particularly relevant in the African setting, where the layering effect of multiple burdens on health results in children with complex problems presenting to general paediatricians. Another unfortunate scenario is that some newly qualified specialists feel that they are left with no option other than to enter the private sector, or to practise abroad, thus exacerbating the SA medical ‘brain drain’. This misalignment of medical career trajectories of the African health workforce needs has been reported. [1,2] These sentiments and concerns were strongly echoed in a recent survey conducted at Red Cross War Memorial Children’s Hospital (RCWMCH), Cape Town, among newly qualified paediatricians and registrars who were nearing completion of their training. The survey was designed to gain insight into a number of potential concerns that these doctors might have related to career trajectories after general specialist training. The questions assessed their opinions about adequacy of training, employment options and the trend towards subspecialty training v. the idea of general paediatrics as a long-term career. The results confirmed fears about many of the aforementioned

scenarios, and revealed an impressive consistency in the answers and opinions around these issues. A preference for remaining as generalists in state practice if the option were open to them was also noted.

Justification for an African hospitalist training programme

Newly qualified specialists who attain employment as general paediatric consultants often find themselves in the unenviable position of having to ‘take the reins’ and run a service without access to more experienced consultant advice and mentorship into the consultant role. The respondents of our survey consistently raised concerns about the lack of adequate training in leadership and management, child protection services, and palliative care. The scope of clinical practice changes significantly from being a ground-level registrar at the ‘front line’ to taking up the baton of clinical governance and being the overall co-ordinator of clinical services, who needs to take a ‘step back’ and appreciate a bird’s-eye perspective. Good communication and leadership skills are crucial to navigating these issues. Having on-site subspecialist support, readily available in most tertiary centres, can blind the physician to the reality of clinical decision-making and hospital practice. Furthermore, many so-called ‘subspecialty’ management decisions should actually be within the generalist’s scope of practice. The generalist must have sufficient confidence and practical knowledge of a wide array of subspecialties to make management decisions when subspecialty support is unnecessary or unavailable, and yet also needs to know when it is appropriate to enlist that support if available. While the training gained in the University of Cape Town (UCT)’s general paediatrics programme is extremely comprehensive and the results are superb, there is still little capacity for advanced training and grooming in all these areas during the 4-year specialist training period.

The definition of a hospitalist

While the term ‘hospitalist’ may be foreign to many SA health practitioners, the concept and overall philosophy behind the idea

November 2017, Print edition

IN PRACTICE

are not. It is traditionally defined as a physician who primarily dedicates his or her practice to the care of hospitalised patients and whose activities include patient care, teaching, research and leadership related to hospital care.[3] The daily practice of state-sector hospital-based general paediatricians in SA fulfils all the criteria to be considered a hospitalist model of care. Clinicians in centres such as George Regional Hospital already practise at this specialised level of paediatric practice, but they have had to equip themselves with these skills through a slow process of exposure and assimilation. Clinicians in these centres were also interviewed and confirmed that they had taught themselves the skills to function as ‘African hospitalists’.

How the hospitalist differs from community paediatrics and child health training

The newly established subspecialty in community paediatrics and child health addresses the issue of improving community-wide child health. This curriculum focuses on the healthcare needs of all children across a system or region, with district health services supported by integrated and mutually supportive referral systems with general specialist (regional) and tertiary hospitals.[4] The paediatric hospitalist and the community paediatrician are different entities. The former is primarily inpatient focused, as opposed to the more primary ‘preventive’ or chronic care role of the latter. In an African context, a certain amount of overlap is inevitable. While optimised primary care is the goal, with a decreased need for reactive hospital-based care of preventable illnesses, for the foreseeable future high volumes of acutely ill patients, often patients with complex problems, who will require quality and skilled inpatient management, are a reality of Africa. The required model for an ‘African hospitalist’ would therefore be an adaptation of the original hospitalist concept whereby the hospitalist provides hospital-level care but remains responsible for a limited amount of outpatient (and some focused outreach) care. From the patient’s and family’s point of view, this is an important quality assurance thread for the continuity of care, whereby patients are guaranteed transition back into primary care with no loss of quality care and with great patient satisfaction. The communication and integration with the community-based family physician is key and does much to enhance holistic care.

The pilot programme of the African hospitalist

A newly qualified specialist trainee (ADD) commenced a pilot project with the African Paediatric Fellowship Programme (APFP) in the Department of Paediatrics and Child Health at UCT to address the task of training paediatric hospitalists.[5] The aim was to create a new 1-year fellowship curriculum, targeting trainees in the immediate post-accreditation period (equivalent to a ‘year 5’ following general paediatrics specialisation) and designed to address the issue of successful transitioning into the role of a hospital-based general paediatrics consultant, namely an ‘African paediatric hospitalist’. The strategy of the APFP is to partner with as many academic African institutions as is feasible, where there is an identified need. Since its inception in 2007, over 80 fellows have trained or are currently in training in general paediatrics or paediatric subspecialties. Returning home to immediately take charge as the lead consultant with the responsibility of setting up and running a paediatric service is a reality for many APFP fellows. During this pilot programme ADD took on a consultant role in the two general medical wards as well as in the short-stay ward and

medical emergency department, with autonomy but also consultant mentorship. Experience was gained in leading consultant ward rounds to formulate management plans, co-ordinating ward morbidity and mortality, as well as multidisciplinary meetings (including palliation and advanced care planning), teaching and mentoring of junior medical staff, child protection team meetings and focused ‘up-skilling’ through work in selected subspecialty clinics. ADD regularly fed back his experiences and suggestions to the project supervisors, who included a senior member of the APFP and two general paediatricians at RCWMCH. The feedback served as a launch pad for further ideas and suggestions to try to build and optimise the core curriculum. In addition to clinical work, the fellowship has integrated a leadership and management training module, which is deemed essential to develop this skill set. Also included is exposure to palliative care interventions. Outreach activities with key peripheral hospitals, as well as a rotation to a secondary-level neonatal unit, were also considered essential to the training experience. Neonatal services and focused outreach both fall within the hospital paediatrician’s scope of work. The role of the mature general hospital paediatrician goes well beyond the ability to manage inpatient wards. Resource management, developing and implementing guidelines, auditing throughputs and handling critical events, as well as control consultations to help mature the hospitalist, are all important components of the hospitalist training. The feedback from the pilot project has been overwhelmingly positive and ADD has gained valuable transitioning experience, boosting his self-confidence to fulfil a senior clinician and leadership role. Furthermore, he reported feeling appreciated as a generalist clinician and that his input and service have added much-needed staff capacity and value at RCWMCH. The survey also revealed a keen interest in and overwhelming support for the hospitalisttraining concept from the registrars nearing training completion, and also from other newly qualified paediatricians. To assess senior medical staff opinion of the fellowship, a second survey was conducted among those consultants at RCWMCH who were responsible for mentoring and supervising ADD during the project. These included both generalist and subspecialist consultants. Opinions on the impact and benefit of a hospitalist fellow on the ward as well as the potential benefits to the trainee were unanimously positive. Furthermore, their recommendations for important content to be included in the fellowship curriculum were very much in line with our own.

Conclusion

While this programme has the training needs of the APFP trainees from outside SA in mind, ultimately any newly qualified paediatrician, including SA candidates, could benefit. This is especially true for those aspiring to be primarily hospital based and for the participants in the RCWMCH survey who unanimously supported the concept. With enough buy-in from key stakeholders, we can work towards making this an option for SA candidates as well and address the ongoing need for effective paediatric hospitalists throughout Africa, inclusive of SA.

Key points

• A new clinical fellowship for an adapted model of the ‘hospitalist’ concept for an African setting has been proposed and piloted at RCWMCH in Cape Town. • The fellowship aims to transition and better equip the newly qualified paediatrician with the required skills to become a

November 2017, Print edition

IN PRACTICE

competent and versatile hospital-based consultant paediatrician in an African setting – an African hospitalist. • The pilot programme has been successful in boosting the confi dence and skills of the pilot fellow, and has gained the overwhelming support of the RCWMCH consultant staff. Acknowledgements. The authors thank the clinicians who contributed to the insights of the programme, namely Prof. Tony Westwood, the paediatrians at George and New Somerset hospitals, and the colleagues who completed the surveys. Author contributions. ADD contributed to the article content, administered the surveys and completed the hospitalist training programme; HB and RD devised the content of the hospitalist training programme, oversaw the first pilot roll-out of the programme, and both proofread the manuscript; and JMW devised the concept of the

programme and the pilot project, and assisted with the development and final format of the manuscript. Funding. None. Conflicts of interest. None. 1. Burch VC, McKinley D, van Wyk J, et al. Career intentions of medical students trained in six subSaharan African countries. Educ Health 2011;24(3):614. http://www.educationforhealth.net/text. asp?2011/24/3/614/101416 (accessed 5 October 2017). 2. Price M, Weiner R. Where have all the doctors gone? Career choices of Wits medical graduates. S Afr Med J 2005;95(6):414-419. 3. Wachter RM, Goldman L. The emerging role of ‘hospitalists’ in the American health care system. N Engl J Med 1996;335(7):514-517. https://doi.org/10.1056/NEJM199608153350713 4. Swingler G, Hendricks M, Hall D, et al. Can a new paediatric sub-specialty improve child health in South Africa? S Afr Med J 2012;102(9):738-739. https://doi.org/10.7196/SAMJ.5714 5. Wilmshurst JM, Morrow B, du Preez A, Githanga D, Kennedy N, Zar HJ. The African Pediatric Fellowship Program: Training in Africa for Africans. Pediatrics 2016;137(1):e20152741. https://doi. org/10.1542/peds.2015-2741

Accepted 2 August 2017.

HEALTHCARE DELIVERY

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

Provision of acute and elective general surgical care at a tertiary facility in the era of subspecialisation

J H Klopper, MMed (Surg); S Rayamajhi, FCS (SA); J J Venter, MB ChB, H Dip Surg (SA); D J de Villiers, FCS (SA), MMed (Surg); N Almgla, MB ChB; J C Kloppers, Dip PEC (SA), MRCS (Ed), FCS (SA), MMed (Surg), FRCS (Gen Surg) (Ed), Cert Gastro (SA) Department of Surgery, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: J H Klopper (juan.klopper@uct.c.za) Background. The need for an acute care and general surgical unit (ACGSU) to provide care for patients previously managed on an ad hoc basis by subspecialist units was recognised by the provincial government of the Western Cape Province, South Africa, the management of Groote Schuur Hospital (GSH) and the Department of Surgery. Objective. To describe the resulting ACGSU and its functioning. Methods. Data available from administrative records, patient files and operating room forms were collected in spreadsheet form for the period July 2013 - November 2016 inclusive. Results. The ACGSU comprised a medical care team of four consultants and four to five trainees. A total of 7 571 patients were seen during the study period, the majority (66.1%) referred from the GSH Emergency Centre. Skin and soft-tissue infections formed the major disease complex. A total of 3 144 operative records were available. The most common procedures were wound debridement and inguinal hernia repairs. Trainees acted as primary surgeon in most cases. Complications (Clavien-Dindo grades I - V) were noted in 25.0% of patients. Conclusions. The ACGSU provides patient management that would otherwise complicate care in the subspecialist surgical units. It serves as a training ground for registrars and stands as a model for other institutions. Further research into the effect on patient care is planned. S Afr Med J 2017;107(11):948-951. DOI:10.7196/SAMJ.2017.v107i11.12335

The duty of treating surgical patients in need of urgent care has historically fallen to the members of different surgical units, such as hepatopancreaticobiliary, gastrointestinal and vascular surgery. [1] This model ultimately required surgeons with little experience or interest in conditions outside their subspecialty to treat emergency cases. Surgery has become increasingly subspecialised as a result of the rapid expansion of medical knowledge and technologies, an increase in patient demand and a variety of personal factors. [1,2] The

trauma care model introduced in the late 1960s showed the benefits of restricting the management of injured patients to a dedicated team and subsequently led to the development of trauma surgery as a subspecialty, with many units established throughout the world.[3,4] An acute care and general surgery unit (ACGSU) similarly isolates surgical patients requiring urgent care and provides a dedicated team of surgeons for their management.[5,6] This model has already been shown to improve outcome.[7-11] It frees other units

November 2017, Print edition

IN PRACTICE

to concentrate on elective care, provides an alternative career path to trauma surgeons in developed-world settings, and potentially allows for planning of the optimal use of resources.[12,13] South African (SA) tertiary institutions have not been immune to the changes in the surgical landscape. The Division of General Surgery at Groote Schuur Hospital (GSH), Cape Town, consists of wellestablished subspecialty units with recognised fellowship training. Concerns regarding the management of emergency, non-trauma surgical conditions and general surgical care were recognised by the provincial government and the institution in 2010. The proposed solution was the establishment of a unit that could respond to the local demand and infrastructure.

Objective

To describe the academic ACGSU that resulted from the initial decision to separate the care of the above cases from the subspecialist units and to describe its functioning in a tertiary surgical setting in SA, so as to offer an example for other institutions with similar demands.

Methods

Retrospective data collected from July 2013 to November 2016 were analysed. As the ACGSU was a new surgical unit, no such collection existed prior to this period. Data were captured from patient files, as well as ward and operating room administrative records. Selected variables were collected in spreadsheet format, and statistical analysis of the data available for the study period was performed using the iPython Jupyter notebook kernel[14] of the Python programming language with the following additional libraries: numerical Python,[15] scientific Python, Statsmodels and Scikit-learn. Data were managed by the Pandas library.[14-19] Descriptive statistics included point estimates and measures of dispersion. Comparison of numerical variables was conducted by appropriate parametric and non-parametric tests. Categorical variables were analysed using the Ď&#x2021;2 test for independence and nonparametric tests if ordinal. A two-tail test hypothesis was used with an alpha value of 0.05 as discriminator for rejection of null hypotheses.

Results

Clinical services

Patient demographics are listed in Table 1. The main function of the ACGSU is the management of surgical conditions requiring urgent attention. The process is initiated at first consultation. These consultations mainly take place in the acute admissions area of the GSH Emergency Centre, but the clinical service extends to all inpatients in GSH, and consultation may take place in the ward or unit in which such patients are present. Elective cases are seen in the weekly clinic as first contact. A total of 7 571 patients were referred during the study period, and the referring facilities are listed in Table 2. The ACGSU also provides an emergency outreach programme to the tertiary care obstetrics and gynaecology unit at Mowbray Maternity Hospital, where most consultations take place during surgery. It is the norm for such patients to be transferred to GSH postoperatively, if appropriate. Administrative admission records were available for 2 483 patients. The logistics of initial admission are listed in Table 3, and the most common admission diagnoses in Table 4. The ACGSU has a minor procedure theatre list for cases performed under local anaesthesia. Typical procedures include biopsies for diagnosis of skin lesions, lymph node excisions, and muscle and nerve biopsies. In addition to this there is a general anaesthesia

Table 1. Patient demographics (N=7 571) Characteristic

Female

Male

Count, n (%)

4 028 (53.2)

3 543 (46.8)

Mean age (years)

Table 2. Referring facilities (N=7 571) Referral unit

n (%)

Emergency Centre

5 003 (66.1)

Other units in Groote Schuur Hospital

1 263 (16.7)

Surrounding hospitals

803 (10.6)

Smaller facilities in Cape Town

334 (4.4)

Other

168 (2.2)

Table 3. Admission logistics (N=2 483) Place of admission

n (%)

Direct admission to ACGSU ward

1 959 (78.9)

Emergency surgery prior to admission

415 (16.7)

Direct admission to the critical care unit

109 (4.4)

ACGSU = acute care and general surgical unit.

Table 4. Most common emergency surgical diagnoses (N=2 483) Condition

n (%)

Non-diabetic skin and soft-tissue infections

611 (24.6)

Diabetic skin and soft-tissue infections

541 (21.4)

Acute appendicitis

213 (8.6)

Acute cholecystitis

124 (5.0)

Bowel obstruction (all causes)

121 (4.9)

abscess list three times a week where the referring doctor can book cases directly. The ACGSU also provides an emergency upper and lower gastrointestinal endoscopy service, with endoscopies performed in the endoscopy suite, at the bedside in critical care units, and in the operating theatre as required. The secondary function of the ACGSU extends to a set of elective procedures. As GSH serves as the primary care facility for the nearby suburbs, general surgical procedures required by this population are performed on two full-day, elective theatre lists. These two lists also provide access to emergency procedures deferred for later attention, such as cholecystectomies presenting >96 hours after onset of symptoms. These patients are booked as elective cases, while still falling under the care of the ACGSU. At discharge, patients are scheduled to attend a weekly clinic if required. All team members share patient management, and formal ward rounds are held twice a day. Patients are not assigned to individual consultants or registrars, so a formal handover round is held every morning and every weekday afternoon to inform all members of the status of and care for each patient. All cases considered to require consultation with other units and departments at GSH are discussed by personal communication with the relevant personnel, with folder notes identifying required information.

November 2017, Print edition

IN PRACTICE

Surgical procedures

The ACGSU has access to the 24-hour theatre facilities at GSH. In addition, a semi-elective overflow list is available on Tuesdays. All emergency cases are formally logged on the booking system of the operating room complex. Case complexity is identified by a system of colour coding applied by the ACGSU surgeon, comprising green, yellow, orange and red cases. All cases except those earmarked as green are discussed with the anaesthetist involved, and based on this individual discussion, colour assignment may be altered. Red cases are considered extremely ill with marked physiological decompensation. Common underlying causes include sepsis and haemorrhage. Despite aggressive resuscitative measures, these patients require immediate surgical care. Orange cases require surgery within an hour for conditions such as arterial flow compromise including limbs and bowel, hollow-organ perforations, and varying degrees of necrotising fasciitis. Yellow cases require surgery within 6 hours and are patients who are physiologically stable despite a serious surgical diagnosis, including peritonitis. Green cases are those in which a reasonable delay would not alter the outcome, yet surgical intervention is required during the current admission. Surgical procedure records were available for 3 144 patients, 1 644 (52.3%) of whom were female. The median age was 46 (range 13 - 100) years for females and 51 (range 13 - 92) years for males (p<0.01). A consultant surgeon acted as primary surgeon in 526 cases (16.7%) and a trainee in 2 618 (83.3%). In the case of elective work, the ratio of consultant v. registrar as primary surgeon was 146/758 (16.2% v. 83.8%). In the case of emergency surgery, this ratio was 180/2 060 (8.4% v. 91.6%) (p<0.01). Overall, consultants assisted registrars in 768 cases. In the case of elective surgery, a consultant assisted a registrar in 552 cases (61.6%), with a more junior doctor assisting in the rest of the cases. During emergency procedures, a more junior team member acted as first assistant to a registrar in 2 068 cases (90.2%), as opposed to 193 cases in which a consultant was the first assistant (p<0.01). When a consultant surgeon acted as primary surgeon, the mean (standard deviation (SD)) duration of the surgical procedure was 88.3 (62.7) minutes, and when a trainee acted as primary surgeon, the mean duration was 52.3 (37.1) minutes (p<0.01). A total of 2 248 procedures (71.5%) were classified as emergencies, while 896 (28.5%) were elective. Of the emergency procedures, 220 (9.8%) were coded as green, 1485 (66.1%) as yellow, 506 (22.5%) as orange and 37 (1.6%) as red. The most common procedures are listed in Table 5. The majority of cases (n=2 377, 75.6%) were performed under general anaesthesia. A total of 601 cases (19.1%) were performed under regional anaesthesia. A total of 2 785 patients (88.6%) were returned to the ward after the procedure. The remaining 359 (11.4%) were admitted to the critical care unit. The Clavien-Dindo classification for postoperative complica tions[20] was available in the last 2 months of the study period (Table 6). A total of 209 deaths (2.8% of all patients referred to the unit) were recorded over the study period. The causes of death are listed in Table 7.

Discussion

The ACGSU described above functions under the auspices of the secondary-level services of the Metro West District of Cape Town, under the administrative management of a principal specialist.

Table 5. Most common surgical procedures (N=2 487) Procedure

n (%)

Minor debridement

358 (11.4)

Inguinofemoral hernia repair

352 (11.2)

Laparoscopic cholecystectomy

308 (9.8)

Ventral hernia repair

308 (9.8)

Laparoscopic appendicectomy

192 (6.1)

Above-knee amputation

160 (5.1)

Open appendicectomy

154 (4.9)

Incision and drainage of abscess

153 (4.9)

Diagnostic laparotomy

141 (4.5)

Major debridement for necrotising fasciitis

129 (4.1)

Partial colectomy

116 (3.7)

Below-knee amputation

116 (3.7)

Table 6. Clavien-Dindo postoperative classification[20] (N=216) Classification

n (%)

No complications

162 (75.0)

Grade I

17 (7.9)

Grade II

15 (6.9)

Grade IIIa

7 (3.2)

Grade IIIb

6 (2.8)

Grade IVa

4 (1.9)

Grade IVb

1 (0.4)

Grade V

4 (1.9)

Table 7. Deaths (N=209) Cause

n (%)

Inevitable (course of illness)

155 (74.2)

Other

17 (8.1)

Therapeutic error

11 (5.3)

System failure

8 (3.8)

Therapeutic error by referring facility

6 (2.9)

Diagnostic error by referring facility

5 (2.4)

Diagnostic error

3 (1.4)

Technical error

3 (1.4)

Technical error by referring facility

1 (0.5)

The staffing of the ACGSU was determined by the posts made available by the provincial government of the Western Cape and by the logistics of the rotational programme that must comply with the requirements of the Health Professions Council of South Africa. Four full-time consultants provide the clinical service. The consultant core comprises two senior consultants, two junior consultants and a senior medical officer. The unit provides tertiary education to a group of four or five registrars per 3-month rotation. They provide full daytime cover for all clinical work, as well as after-hours on-site cover. All registrars in the Division of General Surgery (DGS) are required to complete two 3-month rotations through the ACGSU during their 4-year training. All registrars are available for daytime duties, which

November 2017, Print edition

IN PRACTICE

include ward rounds, ward work, consultations, clinic attendance, and surgery. A single registrar provides on-site after-hours cover. A comprehensive list of surgical procedures is recorded for each registrar. It is used in their formal evaluation and to compile a portfolio required by the College of Surgery of South Africa as entry criteria for the final fellowship examination. Together with a research component, trainees can seek specialist registration with the Health Professions Council of South Africa. The data show that the ACGSU at GSH provides both a clinical service and a broad-based training ground for future surgeons tasked with the care of a diverse population group. The majority of patients (82.8%) referred to the unit were from the Emergency Centre and other units in GSH. Most of these patients were admitted to the ACGSU ward. Approximately one in five, however, required direct transfer to either the operating theatre or the critical care unit. The greatest proportion of the surgical work performed by the ACGSU is emergency in nature, relieving the subspecialist units from the burden of care, as intended by the initial decision to establish this unit. The elective work is smaller in number than the emergency work, because the geographical area of referral for secondary-level surgical work is smaller than the geographical area for referral of emergency cases. This is exacerbated by the fact that the ACGSU serves as tertiary referral centre for emergency surgical care from the surrounding hospitals, which in turn serve their own communities as far as elective surgical work is concerned. Registrars are provided with ample opportunity to act as primary surgeon in a mix of elective and emergency procedures. They are well supported by consultants for elective cases. This assistance is considerably less for emergency cases.

Conclusions

The ACGSU at GSH plays and will play a leading academic role in surgical service delivery and provides technical experience for trainees. It has been shown to be a useful adjunct to the other subspecialist units in the DGS, freeing both their time and resources by taking away their emergency surgical workload. Parameters highlighted during data collection can be of vital importance in planning future healthcare strategies based on the needs of various institutions and countries. Future research should elucidate the effect on patient care in the setting of the ACGSU by way of outcome measurement.

Acknowledgements. None. Author contributions. All the authors contributed equally to the writing of the original article and to the data collection. JHK created the original research project and data collection tool, performed the statistical analysis and completed the revisions. Funding. None. Conflicts of interest. None. 1. Malangoni MA. Acute care surgery: The general surgeon’s perspective. Surgery 2007;141(3):324-326. https://doi.org/10.1016/j.surg.2007.01.008 2. Stitzenberg KB, Sheldon GF. Progressive specialization within general surgery: Adding to the complexity of workforce planning. J Am Coll Surg 2005;201(6):925-932. https://doi.org/10.1016/j. jamcollsurg.2005.06.253 3. Blaisdell FW. Development of the city-county (public) hospital. Arch Surg 1994;129(7):760-764. https://doi.org/10.1001/archsurg.1994.01420310092017 4. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354(4):366-378. https://doi.org/10.1056/NEJMsa052049 5. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: Trauma, critical care, and emergency surgery. Am J Surg 2005;190(2):212-217. https://doi. org/10.1016/j.amjsurg.2005.05.014 6. Hoyt DB, Kim HD, Barrios C. Acute care surgery: A new training and practice model in the United States. World J Surg 2008;32(8):1630-1635. https://doi.org/10.1007/s00268-008-9576-y 7. Cubas RF, Gomez NR, Rodriguez S, Wanis M, Sivanandrum A, Garberoglio CA. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: Impact on timing and cost. JACS 2012;215(5):715-721. https://doi.org/10.1016/j. amcollsurg.2012.06.415 8. Von Conrady D, Hamza S, Weber D, et al. The acute surgical unit: Improving emergency care. Aust N Z J Surg 2010;80(12):933-936. https://doi.org/10.1111/j.1445-2197.2010.05490.x 9. Lau B, Difronzo LA. An acute care surgery model improves timeliness of care and reduces hospital stay for patients with acute cholecystitis. Am Surg 2011;77(10):1318-1321. 10. Gandy RC, Truskett PG, Wong SW, et al. Outcomes of appendicectomy in an acute care surgery model. Med J Aust 2010;193(5):281-284. 11. Shaina S, Dirks R, Davis J. Comparison of outcomes of patients with acute appendicitis between an acute care surgery model and traditional call coverage model in the same community. Am J Surg 2016;212(6):1083-1089. https://doi.org/10.1016/j.amjsurg.2016.09.006 12. Gamelli RL. Organization of faculty practice and resident training in acute care surgery in an academic medical center. Surgery 2007;141(3):302-303. https://doi.org/10.1016/j.surg.2007.01.005 13. Trydestam C, Pratto S, Cushing B, Whiting J. Effect of a dedicated acute care operating room on hospital efficiency. Am Surg 2014;80(1):89-91. 14. Pérez F, Granger BE. IPython: A system for interactive scientific computing. Comput Sci Eng 2007;9(3):21-29. https://doi.org/10.1109/MCSE.2007.53 15. Van der Walt S, Colbert C, Varoquaux G. The NumPy array: A structure for efficient numerical computation. Comput Sci Eng 2011;13(2):22-30. https://doi.org/10.1109/MCSE.2011.37 16. Kubilius J. A framework for streamlining research workflow in neuroscience and psychology. Front Neuroinform 2014;7. https://doi.org/10.3389/fninf.2013.00052 17. Pedregosa F, Varoquaux G, Gramfort A, et al. Scikit-learn: Machine learning in Python. J Mach Learn Res 2011;12(10):2825-2830. http://www.jmlr.org/papers/volume12/pedregosa11a/pedregosa11a.pdf (accessed 4 October 2017). 18. McKinney W. Data structures for statistical computing in Python, Proceedings of the 9th Python in Science Conference, Austin, Texas, 28 June - 3 July 2010. http://conference.scipy.org/proceedings/ scipy2010/mckinney.html (accessed 25 September 2017). 19. Hunter JD. Matplotlib: A 2D graphics environment. Comput Sci Eng 2007;9(3):90-95. https://doi. org/10.1109/MCSE.2007.55 20. Dindo D, Demartines N, Clavien PA. Classification of surgical complication: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240(2):205-213. https:// doi.org/10.1097/01.sla.0000133083.54934.ae

Accepted 24 May 2017.

November 2017, Print edition

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

IN PRACTICE

HEALTHCARE DELIVERY

Kaposi’s sarcoma: Good outcome with doxorubicin, bleomycin and vincristine sulphate (ABV) chemotherapy and highly active antiretroviral therapy P B Hesseling,1 MD; E Katayi,2 MD; P Wharin,3 MD; R Bardin,2 MD; F Kouya,2 MD; D Palmer,2 MD; M Glenn,2 RNN; M Kruger,1 MD epartment of Paediatrics and Child Health, Tygerberg Children’s Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, D Cape Town, South Africa 2 Cameroon Baptist Convention Health Board, Bamenda, Cameroon 3 Beryl Thyer Memorial Africa Trust, Warkton, UK 1

Corresponding author: P B Hesseling (pbh@sun.ac.za)

There is little published information on effective treatment of Kaposi’s sarcoma (KS) in children in low-income countries. We prospectively treated 12 patients with an institutional review board-approved protocol consisting of four monthly courses of doxorubicin (Adriamycin), bleomycin and vincristine sulphate (ABV), with highly active antiretroviral therapy (HAART) plus co-trimoxazole prophylaxis for those who were HIV-positive, with additional vincristine if remission was not achieved after 4 months. Maintenance HAART plus co-trimoxazole was given to all HIV-positive patients. A fine-needle aspirate and CD4+ count were done if possible, and staging was performed according to Mitsuyasu. Eight of ten HIV-positive patients with stage III - IVB disease, and both HIV-negative patients with stage I disease, were in remission after 473 - 1 490 (mean 939) days. One patient died after absconding during treatment, and one died from neutropenia-related pulmonary infection. ABV with or without HAART is an effective treatment option for children with KS. S Afr Med J 2017;107(11):952-953. DOI:10.7196/SAMJ.2017.v107i11.12559

There is a memorandum of understanding between the Department of Paediatrics at Tygerberg Children’s Hospital, Cape Town, South Africa (SA), and the Cameroon Baptist Hospitals in Cameroon to support the Cameroon Baptist Hospitals’ paediatric oncology programme. A recent Cochrane review found a lack of information on the effective treatment of Kaposi’s sarcoma (KS) in children with chemotherapy and highly active antiretroviral therapy (HAART). [1] Published treatment guidelines for the management of KS in resource-limited settings include chemotherapy with the single drugs etoposide, thalidomide and vincristine, with two drugs, namely vincristine and bleomycin, and with three drugs, namely doxorubicin (Adriamycin), bleomycin and vinblastine sulphate.[2] An SA multiinstitutional review of HIV-positive children treated with HAART and unspecified chemotherapy schedules reported a 58% projected 5-year survival rate.[3] In Malawi the combination of vincristine plus bleomycin resulted in a 50% 1-year survival rate.[4] We report the outcome of a prospective study in children with KS in Cameroon treated with ABV, together with HAART for those who were HIVpositive. This combination of drugs was chosen because they have individual activity against KS, and because they were available in this resource-limited setting.

Methods

All patients diagnosed with KS at Banso, Mbingo and Mutengene Baptist hospitals in north-west and south-west Cameroon between October 2011 and August 2015 were staged according to Mitsuyasu. [5] Treatment was with an institutional review boardapproved protocol consisting of doxorubicin 10 mg/m2, bleomycin 15 IU/m2 and vincristine 1.5 mg/m2 intravenously (ABV) every 4 weeks for four cycles. Chemotherapy commenced 4 weeks after

the initiation of HAART, which was continued indefinitely in HIV-positive patients together with daily co-trimoxazole prophy laxis. HAART consisted of triple antiretrovirals adapted for age and weight according to World Health Organization guidelines. Chemotherapy was given at 4-week intervals to limit toxicity. Vincristine 1.5 mg/m2 was continued every 4 weeks for four doses if remission was not achieved. A fine-needle aspirate (FNA) and CD4+ count were recommended investigations. Informed parental consent was obtained. Follow-up was achieved by outpatient visits, telephone calls and home visits. Treatment was free.

Results

Twelve patients, 10 boys and 2 girls aged 2 - 11 (median 7) years, were treated. Two HIV-negative patients presented with a localised skin lesion and localised lymphadenopathy, respectively. The HIV-positive patients presented with stage III (n=3), IVA (n=3) and IVB (n=4) disease. An FNA was performed in 7 patients, and a CD4+ count in 7 (median 144 (range 11 - 946) cells/µL). One HIV-negative patient received additional vincristine. Two deaths occurred, both in HIV-positive patients. One died from febrile neutropenia and pulmonary disease on day 48, while the other did not return after two courses of ABV, his family deciding in favour of traditional medicine, and died of progressive KS on day 390. Both these patients had a CD4+ count of <100/µL. Eight HIV-positive patients were in remission after 1.5 - 50 (median 30) months’ follow-up at the time of writing, and the 2 HIV-negative patients were in remission after 19 and 37 months’ follow-up, respectively. Table 1 sets out details of age, sex, stage, FNA, CD4+ count, treatment and outcome (December 2016). No patients were lost to follow-up.

November 2017, Print edition

IN PRACTICE

Table 1. Clinical and laboratory findings in children with Kaposi’s sarcoma

Case

Age (yr), sex

Stage

HIV

7, M

–

CD4+ count (cells/µL)

FNA

Treatment

Status

Follow-up (mo)

ABV

6, M

IVB

240

HAART/ABV

7, M

IIIB

HAART/ABV

6, M

IVB

HAART/ABV

Died

7, F

IIIB

144

HAART/ABV

2, M

IVB

HAART/ABV

7, M

IVB

946

HAART/ABV

4, M

IVA

HAART/ABV

Died

1.5

ABV+

HAART/ABV

11, M

–

9, M

IIIB

12, M

IVB

HAART/ABV

11, F

IVB

619

HAART/ABV

FNA = fine-needle aspirate; M = male; F = female; – = negative; + = positive; NT = not tested; NS = nonspecific; ABV = doxorubicin (Adriamycin), bleomycin and vincristine sulphate; HAART = highly active antiretroviral therapy; ABV+ = extended vincristine; CR = complete remission.

Discussion

Although the incidence of KS in some African countries is decreasing because of HAART, it remains an important cause of childhood cancer.[6] No effective chemotherapy for patients in lowincome countries has been published to date. We used the above chemotherapy agents because of their individual efficacy and their availability. Although the number of patients is small, treatment with ABV with or without HAART achieved good medium-term survival in HIV-positive and HIV-negative patients, with one possible treatment-related death.

Conclusion

Four cycles of ABV plus HAART in HIV-positive patients achieved good medium-term survival in patients with KS. Acknowledgements. The authors thank research nurses Patience Nfor and Comfort Kimbi for data collection.

Author contributions. All the authors were actively involved in protocol design, patient diagnosis and management and the preparation of the manuscript. Funding. Funding was received from the Swiss Cancer League, Beryl Thyer Memorial Africa Trust and World Child Cancer. Conflicts of interest. None. 1. Anglemyer A, Agarwal AK, Rutherford W. Treatment of Kaposi sarcoma in children with HIV-1 infection. Cochrane Database Syst Rev 2014, Issue 1. Art. No.: CD009826. https://doi. org/10.1002/14651858.CD009826.pub2 2. Molyneux E, Davidson A, Orem J, et al. The management of children with Kaposi sarcoma in resource limited settings. Pediatr Blood Cancer 2013;60(4):538-542. https://doi.org/10.1002/pbc.24408 3. Davidson A, Wainwright R, Stones DK, et al. Malignancies in South African children with HIV. J Pediatr Hematol Oncol 2014;36(2):111-117. https://doi.org/10.1097/MPH.ObO13e31829cdd49 4. Chagaluka G, Stanley C, Banda K, et al. Kaposi’s sarcoma in children: An open randomised trial of vincristine, oral etoposide and a combination of vincristine and bleomycin. Eur J Cancer 2014;50(8):1472-1481. https://doi.org/1016/j.ejca.2014.02.019 5. Mitsuyasu RT. Clinical variants and staging of Kaposi’s sarcoma. Semin Oncol 1987:14(suppl 3):13-18. 6. Steliarova-Foucher E, Colombet M, Ries LAG, et al., eds. International Incidence of Childhood Cancer, vol. III (electronic version). Lyon: International Agency for Research on Cancer, 2017. http://iicc.iarc. fr (accessed 16 February 2017).

Accepted 28 July 2017.

November 2017, Print edition

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

IN PRACTICE

MEDICINE AND THE LAW

Protecting personal information: Implications of the Protection of Personal Information (POPI) Act for healthcare professionals M Buys, MB ChB, DA (SA), MMed (Anaes), FCA (SA) Specialist anaesthetist, private practice, Western Cape, South Africa Corresponding author: M Buys (tdeflamingh@gmail.com)

Careless handling of patient information in daily medical practice can result in Health Professions Council of South Africa sanction, breach of privacy lawsuits and, in extreme cases, serious monetary penalty or even imprisonment. This review will focus on the Protection of Personal Information (POPI) Act (No. 4 of 2013) and the implications thereof for healthcare professionals in daily practice. Recommendations regarding the safeguarding of information are made. S Afr Med J 2017;107(11):954-956. DOI:10.7196/SAMJ.2017.v107i11.12542

Although promulgated in November 2013, the Protection of Personal Information (POPI) Act (No. 4 of 2013)[1] still awaits enactment, although sections of the act are already active, dealing mainly with the appointment of the Information Regulator, which was made in December 2016 and formally introduced in February 2017.[2] Following the proclamation of enactment by the President of the Republic of South Africa (the exact date of which is still unsure), individuals and organisations will have a year’s grace period to implement the necessary safeguarding measures before the Information Regulator will implement fines and initiate prosecutions. The main purpose of the POPI act is to protect the processing of personal information by public and private bodies. Balancing the right to privacy against the reasonable right to access of information is paramount in an era that supports both free access to information and personal exposure on social media and digital platforms. The act bears importance for every South African, as it protects the distribution and prevents the abuse of personal information by individuals and corporations, domestically as well as internationally.

Intentional and unintentional exploitation of information

Personal information can be exploited intentionally and unintentionally. Intentional publication of personal information in the healthcare setting is both unethical and illegal,[1,3] as it directly contravenes patient confidentiality. Medical professionals and healthcare institutions have an obligation to maintain confidentiality by virtue of their profession,[1] and the consequences of transgressions can be severe. A clinical example would be mentioning a patient or showing a photograph of a patient publicly (for instance, on social media or other public communication platforms). The roles and implications of social media in the healthcare profession are unfortunately still unappreciated, as is evident by a recent example of a nurse practitioner who mentioned a high-profile politician’s family member in her Facebook update, thereby revealing her medical treatment.[4] This led to the employee’s immediate dismissal, and necessitated a formal apology to the patient and her family. The interested reader is referred to an excellent recent review of the ethical implications of social media in the healthcare profession.[5]

This article rather aims to focus on the unintentional publication of patient information, which is a more subtle entity, but can carry equally severe consequences. All healthcare professionals and administrative staff acquire personal information on a daily basis. Merely by opening an account or divulging a medical history, a patient provides healthcare professionals with confidential personal information. Legally, this information is regarded as a patient’s personal ‘property’, which is divulged for a specific purpose, in the tacit understanding that such information will only be used for that particular purpose. Acquiring patient information is an integral part of the healthcare business, for both billing purposes and service delivery. Obtaining this information is not necessarily illegal, provided it meets the narrow requirements for maintaining patient confidentiality and the protection of patient information. However, should any personal information be accessed and/or published from a personal electronic device (e.g. a smartphone, iPad or personal computer), digital storage devices (iCloud, Dropbox, external hard drives) or other data-capturing aids (notebooks or files), it can result in personal harm or defamation. In such an event, the initial information-acquiring person (the healthcare professional or staff member), also known as the responsible party, is directly to blame whether they are primarily responsible for publishing the information or not.[1] Therefore not only is the divulging of information (intentionally or unintentionally) illegal, but this also puts the onus on the responsible party to ensure that such information is protected. According to the Health Professions Council of South Africa (HPCSA) guidelines on the protection of personal information,[6] a significant number of improper disclosures of patient information happen unintentionally. It is therefore important to understand the legal freedom and boundaries of the doctor-patient relationship. Healthcare professionals must be educated regarding the lawful processing of personal information, the rights of our data subjects (patients) and the consequences of careless handling of data. These are set out in the POPI Act.

What does POPI say?

Sections of the POPI act of note to the healthcare professional are included in this review. This summary cannot be regarded as a legal

November 2017, Print edition

IN PRACTICE

document, but merely as a guideline for healthcare professionals. It focuses on five areas from the act: • lawful information processing • the rights of the data subject • what is considered personal information • what recording of that information entails • who can be seen as the responsible party.

Lawful information processing

Table 1 gives examples of illegal information processing. Lawful information processing[7] by the responsible party must include the following characteristics: (i) Minimality: Information should only be processed to an extent that is adequate for the relevant purpose, for example, photographing only the section of the body that is being treated, not the whole body, or having a clerk acquire only information necessary to assist with billing and not intricate medical detail. (ii) Informed consent from the data subject: This includes the principles of competence (mental and legal capacity), voluntariness (which includes autonomy, non-coercion and the right of objection) and disclosure of pertinent information (alternatives and risks). This can be in written or verbal form, but verbal consent must always be noted in the clinical notes. If data are intended for publication, written consent is compulsory. (iii) Collection from the data subjects themselves: The data subject provides the information (and not a third party) to assure its accuracy. (iv) Collection of data must be related to a specific function or requirement: For example, one might collect geometric data in order to plan pharmacological treatment, collect personal information for billing purposes or photograph a wound for treatment follow-up. (v) Retention and restriction of records: The minimum duration for medical-information retention by law is 5 years. This may be extended for historical, statistical or research purposes. Personal records must be destroyed/deleted/de-identified as soon as reasonably possible. If someone were to gain access to records that have surpassed the retention period (older than 5 years), and information processing of those records was no longer a necessity for the primary purpose they were acquired for, the breach would be indefensible. (vi) Reasonable security regarding the safeguarding, integrity and confidentiality of personal information: The processing of and access to personal information of data subjects must be restricted, and data subjects must be notified in the event of a security compromise. Reasonable security measures for an individual professional may not require the same level of sophistication as those for a large group practice. Table 1. Examples of illegal information processing • Taking a photograph with your mobile device of a patient’s wound (or any body part, for that matter) without his/her explicit consent • Taking a photograph of the patient’s hospital label and storing it on a mobile device, without formally safeguarding access to this information • Storing patient information on any data-storage device/cloud/ data bank, without restricted access • Accessing patient information (e.g. blood results, radiography or medical notes) on a public computer and leaving it open • Storing (on paper or in electronic files) patient information without any anticipated legal, research, or administrative value, for longer than 5 years

The rights of the data subject

The rights of the data subject[8] include: (i) Notification that personal information about him/her is being collected. This is an important principle of informed consent and can be done verbally or in writing. A patient has the right to know that information of any nature is being collected from him/her. (ii) Notification if his/her information is accessed by an unauthorised person (anyone other than the responsible party), i.e. if a breach in security has occurred. This is compulsory in terms of section 22 of POPI, and there are very specific reporting steps that need to be taken. This can present an ethical dilemma, should a breach occur that no-one would know about unless you reported it yourself. (iii) A request to correct, destroy or delete their personal information. This links to the principle of voluntariness during informed consent. (iv) A reasonable objection to processing of their information. (v) The submission of an inquiry or complaint to the Information Regulator if he/she suspects interference with the protection of personal information of any data subject.

Personal information

Personal information[9] is regarded as personal property, and includes: (i) information regarding race, gender, sex, pregnancy, marital status, ethnic origin, sexual orientation, age, physical or mental health, disability, religion, culture, language and birth (date, place, time, etc.); (ii) information regarding education and employment; (iii) any identifying number, symbol or address; and (iv) biometric information. The POPI act does not apply to the processing of personal information of a purely personal nature (household activity), data that have been properly de-identified (where re-identification is impossible), or information that involves public safety (such as terrorist activity). The act makes an exception for medical professionals and healthcare institutions regarding the prohibition against obtaining information relating to a person’s health or sex life, since these are generally a necessity for proper treatment and care. However, acquiring this information outside the healthcare setting is deemed to be illegal.

Recording of personal information

Personal information[9] can be recorded by any of the following means: (i) writing on any material; (ii) recording or storing information by means of any datacapturing device; (iii) using maps, plans, graphs or drawings of a personal nature, or which identify the subject in any way; or (iv) using photographs, film, negatives, tape or another device in which visual images are embodied.

Responsible party

Recorded material must be in the safe possession of a responsible party.[1] This refers to a public or private body or person who determines the purpose of and the means of processing of personal information obtained from the data subject. In the healthcare setting this could be an individual healthcare professional, or a healthcare institution.

November 2017, Print edition

IN PRACTICE

What does the HPCSA say?

Booklet 10 of the HPCSA’s practice guidelines[6] deals with patient confidentiality, and clearly supports the protection of patient information. It is recommended that if the disclosure of patient information is necessary patient consent be obtained, disclosure minimised as much as possible, and anonymity must always take preference. The HPCSA recognises that a significant number of improper disclosures happen unintentionally, and stresses that clerks and receptionists should be trained in patient confidentiality and retention of disclosure. The HPCSA states: ‘Healthcare professionals should not discuss information about patients where they can be overheard or leave patients’ records where they are vulnerable to disclosure, either on paper or electronically, where they can be seen by other patients, unauthorised healthcare personnel or the public. Healthcare practitioners should endeavour to ensure that their consultations with patients are private.’[6] The recommendations made by the HPCSA state that each healthcare provider is responsible for the safeguarding of their patients’ information. Stringent precautions should thus be taken to assure the security of the data storage unit used to store patient information, and ‘if necessary, healthcare practitioners should take appropriate authoritative professional advice on how to keep information secure before connecting to a network. They should record the fact that they have taken such advice.’ The same security requirements apply to the receiving or sending of patient information via fax, mobile device or email, as ‘the data cannot be intercepted or seen by anyone other than the intended recipient.’[4] Healthcare practitioners should be aware of the fact that information sent by email may be intercepted.[6]

When can a healthcare professional be held liable?

The responsible party is guilty of an offence if: (i) information was obtained without consent; (ii) information was published or accessed by an unauthorised party; (iii) reasonable harm or distress was caused to the subject; (iv) the responsible party failed to take reasonable steps to prevent access to the information; or (v) the responsible party failed to report a breach to the subject or the Information Regulator. The penalty for a breach of privacy is related to the severity of the harm or distress caused. This can include termination of employment, sanctions by the HPCSA (including being struck off the roll of practitioners), a damages award of monetary compensation to the affected data subject (up to ZAR10 million) and imprisonment for a maximum of 10 years.[10]

Recommendations

Given the intended legislation, it is recommended that the following are considered: (i) Always inform the patient if acquiring their personal information, notarising the consent if it was a verbal agreement. Written consent is necessary when information is disclosed or published. A reasonable suggestion is to have a discussion of these issues on the first consultation with a patient, and to notarise this discussion. This will not only properly inform the patient, but also safeguard the professional.

(ii) The recording of personal information should always be done accurately, preferably using information primarily from the data subjects themselves, and involve only the essential information as required for the specific purpose for which it is being collected. (iii) When publishing patient information, always assure full de-identification. Written consent is still a requirement. (iv) The retention of records and handling of patient information should be done securely, as recommended by the HPCSA guidelines. (v) The deletion of the records after 5 years’ retention is necessary, with the exception of records with historic or academic value, or those involving anticipated legislation. (vi) The above steps should be executed in terms of a written POPI policy in the practice. The policy must be communicated to everyone who may have access to patients’ private information in the workplace. This is one of the minimum reasonable measures expected by the Information Regulator.

Conclusion

The nature of the healthcare ‘business’ is personal and interesting. It is a normal human reaction for healthcare professionals to want to share their interesting cases and experiences with colleagues, and even friends and family. However, we are now forbidden by law to do so in any format, including on social media platforms. This requirement probably necessitates a significant change in the mindset of the medical fraternity, as the time-honoured sharing of information between colleagues cannot continue given the new legislation. Should personal patient information be leaked or published from a personal data-storage device, the responsible party or physician who acquired that information can be held liable for damages incurred. However, the threat of legal action should not drive the medical profession’s attitude. We should support the legislation because it sets out in legal terms what we should already know is the right thing to do. Acknowledgements. The author wishes to acknowledge Prof. André Coetzee and Mr Gerhardt van der Merwe (Medical Protection Society), whose professional advice played a major role in the preparation of this document. She also wishes to extend her gratitude to Dr Pamela Scheepers for her help in grammatical correction, and Dr Willem Buys for his support. Author contributions. Sole author. Funding. None Conflicts of interest. None. 1. South Africa. Protection of Personal Information Act No. 4 of 2013. 2. Information Regulator (South Africa). http://www.justice.gov.za/inforeg/ (accessed 16 June 2017). 3. South Africa. National Health Act No. 61 of 2003. 4. Malefane M. Nurse fired over Zuma and wife Facebook rant. Sowetan Live, 3 July 2017. http://www. sowetanlive.co.za/news/2017/03/07/nurse-fired-over-zuma-and-wife-facebook-rant (accessed 7 March 2017). 5. Grobler C, Dhai A. Social media in the healthcare context: Ethical challenges and recommendations. S Afr J Bioethics Law 2016;9(1):22-25. https://doi.org/10.7196/SAJBL.464 6. Health Professions Council of South Africa. HPCSA Guidelines for Good Practice in the Healthcare Professions. Confidentiality: Protecting and providing information. Booklet 10. Pretoria: HPCSA, May 2008. 7. South Africa. Protection of Personal Information Act No. 4 of 2013. Chapter 3: Conditions for lawful processing of personal information. 8. South Africa. Protection of Personal Information Act No. 4 of 2013. Chapter 2: Application provisions. 9. South Africa. Protection of Personal Information Act No. 4 of 2013. Chapter 1: Definitions and purpose. 10. South Africa. Protection of Personal Information Act No. 4 of 2013. Chapter 11: Offences, penalties and administrative fines.

Accepted 3 July 2017.

November 2017, Print edition

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

REVIEW

Investigating nystagmus in patients with traumatic brain injury: A systematic review (1996 - 2016) H de Clercq, MCommunication Pathology (Audiology); A Naudé, PhD; J Bornman, PhD Centre for Augmentative and Alternative Communication, Faculty of Humanities, University of Pretoria, South Africa Corresponding author: H de Clercq (hendrika@hdcinc.co.za) Background. Traumatic brain injury (TBI) is a health and socioeconomic concern worldwide. In patients with TBI, post-traumatic balance problems are often the result of damage to the vestibular system. Nystagmus is common in these patients, and can provide insight into the damage that has resulted from the trauma. Objective. To present a systematic overview of published literature regarding nystagmus in patients with TBI. Methods. Nine databases and platforms were searched during October 2016 for articles published between 1996 and 2016. Studies of any research design and published in English that focused on nystagmus in patients with TBI were considered for inclusion. A total of 110 articles were screened once duplicates had been removed, and 29 full-text articles were assessed. Eleven articles were included in the quality appraisal phase (using the McMaster tool), after which 10 articles were included in this review. Results. This review describes nystagmus in 713 patients, and all articles reviewed described the type of assessment method that was used. However, the results lacked comprehensive data regarding the assessment, measurement and description of nystagmus in TBI patients, or the possible link and relationship between nystagmus and TBI. Conclusions. This systematic review indicated that: (i) there is a growing body of evidence that benign paroxysmal positional vertigo should be considered during the medical examination of all patients suffering from head trauma; (ii) all patients with TBI should undergo visual (eye movement) and vestibular examination; and (iii) future studies should include quantitative measurements of eye movements and nystagmus. S Afr Med J 2017;107(11):957-964. DOI:10.7196/SAMJ.2017.v107i11.12472

Traumatic brain injury (TBI) is a non-degenerative, non-congenital injury that occurs when a sudden trauma causes structural and/or physiological damage to the brain.[1] TBI is a health and socioeconomic concern worldwide owing to its impact not only on the individual person suffering from the injury, but also on the national health and economic growth of a country.[2] The declared global prevalence rate of TBI of 200 per 100 000 people per year is considered to be an underestimate,[3] probably because mild TBI, also referred to as concussion, is often undiagnosed, misdiagnosed and/or untreated. [4,5] The prevalence of TBI is estimated to be lower in high-income countries than in low- and middle-income countries (LMICs).[2] TBI is especially prominent in LMICs facing a high preponderance of risk factors for causes of TBI, and with inadequately prepared health systems to address the associated health outcomes. In the Western hemisphere, TBI is the leading cause of mortality in persons <45 years of age.[6] Population-based studies in LMICs such as South Africa (SA), Taiwan and India suggest even higher rates. This is mainly because of road traffic accidents. Indeed, males in South-East Asia and Africa have the highest and second-highest incidences, respectively, of fatalities related to road traffic injuries in the world, and it may be assumed that a significant proportion, if not the majority, of these deaths can be attributed to TBI.[6] According to the National Institute of Occupational Health of SA,[7] the incidence of TBI in SA is about 316 per 100 000 population per year. The reported number of new cases of TBI in SA is about 89 000 per year, making SA one of the countries with the highest rates of new cases in the world.[8] Irrespective of the incidence and prevalence of TBI, it is a complex injury with a broad spectrum of symptoms and disabilities, including communication and cognitive impairment.[9] The effect of TBI on a person and his or her family can be devastating.

TBI results in a cascade of physical, emotional, neurological and sleep-related symptoms that include headaches, tinnitus, light-headedness, dizziness, blurred vision, fatigue, irritability and memory disorders.[10-12] Between 30% and 65% of people with TBI suffer from some form of dizziness and/or have balance problems at some point during their recovery.[11,13] Balance is the ability to maintain one’s centre of mass over its base of support.[14] With a well-functioning balance system (vestibular system), a person can see clearly while moving, identify orientation with respect to gravity, determine direction and speed of movement, and make automatic postural adjustments to maintain posture and stability in various conditions and activities.[14,15] The area most associated with balance is the region of the inner ear known as the vestibular system. The vestibular system consists of a complex sensory organisation that involves communication between the central and peripheral vestibular systems as well as the ocular system, the postural muscles, the brainstem and the cerebellum to regulate and control balance and sense of motion.[16,17] In patients with TBI, post-traumatic dizziness or balance problems are often the result of damage to the vestibular system.[14,15] The severity of post-traumatic balance problems depends on the location, type and severity of the brain injury. A dysfunctioning vestibular system results in symptoms such as dizziness, vertigo (an illusionary sensation of spinning of oneself or the environment), nausea, difficulty focusing on specific objects (which affects the ability to read or watch television, drive a car and read road signs), a sense of falling over while walking, and difficulty walking on uneven surfaces or in the dark.[12,18] Symptoms resulting from vestibular disorders can diminish quality of life and affect all aspects of a person’s activities of daily living such as walking, driving, going shopping, meeting

November 2017, Print edition

REVIEW

with friends and working. They can also contribute to mental health disorders such as anxiety and depression and have a negative effect on a person’s work and ability to concentrate.[19] Disorders of the vestibular system can result from damage to either the peripheral or the central vestibular system. The peripheral vestibular system consists of the vestibular apparatus, which is divided into five end-organs. These are the three semicircular canals (superior, posterior and horizontal) that sense rotational head movement or angular acceleration in the yaw, pitch and roll planes, and the two otolith organs (saccule and utricle) that sense linear acceleration, head tilt and gravity.[1] These end-organs provide peripheral sensory input and in conjunction with the central systems, provide the brain with feedback regarding the movements of the body and head. Effective co-ordination of activities and balance involves a complex integration of the sensory, motor-programming and musculoskeletal systems.[20] Dysfunction along any pathway in the vestibular system can lead to symptoms such as dizziness and/ or vertigo.[18] The central vestibular system has four functional connections from the vestibular nuclei, namely: • Cerebellar connections that regulate body balance and posture and connect to the ocular motor neurons[16] • Connections with higher centres for conscious perception of changes in posture and movements, and the mediation of appropriate adjustments of voluntary actions[16] • Connections to the back muscles that contribute to the control of posture and adjust reflexes of the body in response to changes in position and movement[16] • Connections to the ocular muscles that mediate the important vestibulo-ocular reflex through which control is exerted over involuntary eye movements that are triggered by movements of the head.[16] The main types of vestibular injuries associated with TBI are benign paroxysmal positional vertigo (BPPV) (the most common peripheral vestibular disorder), labyrinthine injury and traumatic endolymphatic hydrops. Other injuries include brainstem and cerebellum injuries.[21] One of the most important considerations when assessing vestibular disorders is the presence and description of nystagmus.[21] Nystagmus is defined as involuntary, repetitive to-and-fro eye movements initiated by a drift of the eye away from the object of interest or focus.[22] Nystagmus occurs when the part of the brain or inner ear that regulates eye movement and eye positioning does not function correctly, resulting in the involuntary, rapid movement of the eyes. In TBI, the shearing forces in the brain due to the injury or trauma can often cause damage to the vestibular system, leading to nystagmus.[11] Nystagmus can be described based on its presence or absence, the position of the eye while the nystagmus is observed, the intensity (rate) of the nystagmus, the direction of the nystagmus (based on the slow-phase component) and whether it is present with or without a fixation point for the person to focus on. Nystagmus can be either spontaneous (occurring without any movement) or induced by external factors such as head and body movements. There are two categories of nystagmus, namely congenital and acquired. Acquired nystagmus can be caused by a disease (e.g. vestibular neuritis), head injury (e.g. TBI) or a neurological pathology (e.g. acoustic neuroma). There are several different types of pathological, acquired nystagmus, of which the most common are spontaneous nystagmus (with or without fixation), positional or positioning nystagmus (occurring with or after head or body

movement), gaze-evoked nystagmus (only present in specific eccentric eye gaze positions), optokinetic nystagmus (only abnormal with lowered velocity of eye movements), pendular nystagmus (independent eyeball motion with vertical, horizontal and torsional nystagmus), seesaw nystagmus (alternating elevation and intorsion of one eye and simultaneous depression and extorsion of the other), and periodic alternating nystagmus, which is a strictly horizontal nystagmus that predictably oscillates in direction, amplitude and frequency. The direction of the nystagmus is defined by the direction of its quick phase. Nystagmus can occur in any direction (horizontal, vertical or torsional) or in a combination of these directions, and it has several different possible waveforms.[13] The type and direction of the nystagmus are determined by the pathophysiology or cause of the pathology. Detailed assessment of the nystagmus is therefore a critical component in the diagnosis of patients with vestibular disorders and the key to successful management of these patients in an attempt to improve their quality of life. The effects of nystagmus on a person differ depending on the type and intensity of the nystagmus. Individuals with acquired nystagmus would generally have difficulty reading or scrolling on a computer, watching television and reading fine print; they would have poor depth perception, decreased balance, and difficulty walking on uneven surfaces or crossing a busy street, and might have difficulty maintaining eye contact. People with nystagmus, and with balance problems in general, may be more affected by emotional and physical factors such as stress, tiredness, nervousness or unfamiliar surroundings than people without these problems. These factors have a negative impact on the person’s mental health and vocation. Not only does SA have a high incidence of TBI,[8] it also has the highest rate of new cases reported worldwide.[6] This, together with TBI’s diverse effect on the individual, underscores the importance of obtaining a clear description of the nystagmus that could be present to improve the diagnosis and treatment of patients with any degree of TBI. There is currently a paucity of literature describing the presence and specific type of nystagmus in patients with TBI, as well as the possible link between the severity of TBI and the intensity of the nystagmus.

Objective

The primary purpose of this research was to use a systematic review with a multiple perspective to describe and analyse the literature that examined articles describing nystagmus in patients with TBI from 1996 to 2016. The multiple perspective used included the following: • A description of the participants (demographic information) • A description of the assessment method/s used to measure nystagmus (high or low technology) • A description of the nystagmus observed in these patients (eye position, type, intensity, direction and fixation) • The optimal time to measure nystagmus in patients with TBI • The possible link between the severity of the TBI and the intensity of the nystagmus. The year in which the article was published, as well as the journal in which it was published, was also noted.

Methods

Search strategy

This systematic search aimed to obtain a comprehensive list of published articles (including grey literature) on nystagmus in patients with TBI. The search strategy followed the population, exposure and outcome (PEO) format and employed keywords and Medical Subject Heading

November 2017, Print edition

REVIEW

(MeSH) terms related to each of these three components. The keywords used in the systematic review are depicted in Table 1. Search concept combinations were ‘TBI AND nystagmus’, ‘TBI AND nystagmus AND assessment’, ‘TBI AND nystagmus AND assessment AND vestibular’, and ‘TBI AND nystagmus AND assessment AND vision’. Nine databases and platforms (WorldCat, Medline, PaperFirst, ScienceDirect, SA ePublications and Journal Collection, BioOne, JSTOR Health and General Sciences, Collection, and JSTOR Life Sciences Collection) were considered relevant and searched during October 2016 for articles published between 1996 and 2016 using the keywords and MeSH terms shown in Table 1. Google Scholar was used to search the reference lists of the included articles for additional relevant articles that might meet the inclusion criteria (grey literature).

TBI. Only studies that comply with the criteria as set by the PEO components were considered for inclusion in this review. A summary of the eligibility criteria is presented in Table 2.

Study eligibility

Outcomes To meet the main aim of the review, namely to investigate nystagmus in patients with TBI, four sub-aims were identified: 1. Describing nystagmus in patients with TBI in terms of: • position: primary or gaze-related nystagmus • type: pendular or jerk nystagmus • intensity: rapid or slow • direction: horizontal, vertical or rotatory nystagmus • with or without fixation: whether the nystagmus is present with or without fixation 2. Describing current assessment methods used to measure nystagmus in patients with TBI 3. Establishing how soon after the onset of TBI nystagmus should be measured

All relevant published studies that used either qualitative or quantitative study designs were eligible for inclusion. Review articles, editorials and opinion pieces that did not contain primary data were excluded. For inclusion, studies also needed to have been published in English between January 1996 and October 2016 and be directly related to nystagmus and patients with TBI. This time period is significant because the US Congress passed the Traumatic Brain Injury Act in 1996 (P.L. 10-166) and the bill was signed by President Clinton on 29 July 1996. US Federal funds were subsequently awarded to states by means of a competitive grant process with the aim of developing, expanding and improving access to service delivery for individuals with TBI and their families. The result was an increased amount of research, and subsequently publications, on

Population The current review covered all studies that included participants with TBI. No exclusions were made based on participant criteria in terms of the type, severity or duration of the TBI. Exposure The review included articles with information on the assessment of nystagmus in TBI patients. All assessment methods (both highand low-technology types of assessments) were included and are important for describing the outcomes of the review.

Table 1. Search terms and keywords used based on each of the PEO components PEO component Population

Search concept TBI

Exposure

Assessment

Outcome

Nystagmus Vestibular Vision

Search keywords (including MeSH terms) TBI; traumatic brain injury; concussion; brain trauma; head trauma; brain injury; head injury; closed head injury; closed brain injury; closed head trauma; closed brain trauma assessment; test; evaluation; Frenzel; postuography; VNG; ENG; videonystagmography; eletronystagmography nystagmus vestibular; dizziness; vertigo visual acuity; gaze stabilization; GST; dynamic visual acuity; DVA

Truncation symbols used traumatic brain injur*; brain traum*; head traum*; brain injur*; head injur*; closed head injur*; closed brain injur*; closed head traum*; closed brain traum* assess*; test*; evaluat*; *nystag*

dizz*

PEO = population, exposure and outcome; MeSH = Medical Subject Heading; TBI = traumatic brain injury; VNG = videonystagmography; ENG = electronystagmography; GST = gaze stabilisation test; DVA = dynamic visual acuity.

Table 2. Inclusion and exclusion criteria based on each of the PEO components PEO component Population

Exposure

Outcome

Inclusion criteria Patients with TBI, regardless of time of onset of nystagmus, gender, age or ethnicity All studies were included that had a primary focus on assessment or testing (high or low technology) Studies included must describe at least one of the four outcomes of the review

Exclusion criteria Patients without TBI, including patients with nystagmus but without TBI Studies dealing with intervention or rehabilitation

To describe the outcomes, the assessment of nystagmus in TBI patients needs to be determined Studies not describing at least one of This review aims to describe the review’s outcomes nystagmus in patients with TBI; studies that do not contribute to at least one of the review’s aims will not be included in the review

PEO = population, exposure and outcome; TBI = traumatic brain injury.

Rationale Focus of the review is on nystagmus in patients with TBI

November 2017, Print edition

REVIEW

4. Describing the relationship between the severity of the TBI and the severity of the nystagmus. Only studies that described at least one of these outcomes were included in the review.

Data extraction and synthesis

A four-phase process was used to assess studies for inclusion in this review and is presented as a PRISMA flow diagram in Fig. 1. Phase 1: Identification Two reviewers (HdC and AN) independently screened all the identified potential studies at title level. Both reviewers are dually qualified as speech-language therapists and audiologists, and have over 10 years’ clinical experience. The reviewers discussed their recommendations and were in agreement about the studies to be excluded at this level of the selection process. Phase 2: Screening The two reviewers (HdC and AN) used the same procedure as in phase 1 to independently screen studies at abstract level to determine the relevance of each study for inclusion in this review. Consensus was reached on inclusion after the results of the screening process had been discussed. A Cronbach’s alpha score of 0.99 was obtained, which indicated a high internal consistency. The third reviewer (JB) independently screened 20% of the articles (n=16) at abstract level, and although the third reviewer was blind to the scores, 100% agreement with the first two reviewers on the scores allocated to each reviewed study was obtained.

Phase 4 Included

Phase 3 Eligibility

Phase 2 Screening

Phase 1 Identification

Phase 3: Eligibility and data extraction Full-text articles were retrieved and independently assessed by both reviewers (HdC and AN) to determine their inclusion in the critical appraisal stage of the review. Data were extracted independently by both reviewers (HdC and AN) and subsequently recorded onto a custom-designed data extraction spreadsheet. Consensus was reached between the reviewers regarding minor discrepancies in the data extraction process. The following information was extracted verbatim and recorded onto the data extraction spreadsheet from each study that was included: • Publication data: author, year, aim/s of the study and country of study

Records identified through database searching N=173

Records after duplicates removed n=110

Records screened n=80

Records excluded n=51

Full-text articles assessed for eligibility n=29

Full-text articles excluded, with reasons n=18

Fig. 1. PRISMA diagram depicting the study selection process.

Participants in the study: age and gender of patients with TBI Intervention: details of the intervention described in the study Control: details of the control conditions Outcomes: description of nystagmus as described in terms of the four aims of the review.

Twenty-nine full-text articles were retrieved and assessed for eligibility according to the data extraction list of inclusion criteria. Of these 29 studies, 18 did not meet the inclusion criteria and were excluded for various reasons, such as study referring to TBI, but focusing more on migraine (n=2), surgery (n=2), genetic causes (n=1), neck or head pain (n=1), cognitive deficits (n=2), epilepsy (n=1), alcohol intoxication (n=1), cerebral palsy (n=2), ocular or neurological diseases (n=2), acoustic trauma (n=1), general brain injury (n=1), syndromes (n=1), and stroke and neuroimaging (n=1). The reviewers (HdC and AN) had an initial agreement score of 93% (27 out of 29 articles) and then discussed the two articles on which they did not initially agree. Upon discussion, consensus was reached and they identified 11 studies for review (HdC and AN). All 11 studies were checked by the third reviewer (JB) and found suitable for inclusion in the review (with an agreement score of 100%). Phase 4: Inclusion A total of 11 studies were included in this review, based on the fourphase assessment process used to determine the eligibility of each study.

Critical appraisal

The type of research design was not a criterion for this review, and as such, the design-generic McMaster critical appraisal tool was selected for critical appraisal.[23] The McMaster has a total of 16 questions, of which only 14 are quantifiable. A binary scoring system was used (1 = yes; 0 = no). Since question 5 was not applicable (none of the appraised studies were intervention studies), questions 5a, 5b and 5c were not appraised and were therefore not included in the score. There remained 11 articles that could be used. Each article was subsequently appraised and allocated a score out of 11, which was then converted to a percentage. All 11 included articles were independently reviewed and scored by reviewers HdC and AN to ensure inter-rater reliability. Inter-rater reliability was calculated with the following formula, and a reliability score of 98.34% was obtained. Number of agreed scores 100 × Number of items × Number of articles 1 119 100 × = 98.34% 121 1

Additional records identified through other sources N=0

Studies included in qualitative and quantitative synthesis n=11

• • • •

The agreed scores for each article are set out in Table 3. The third reviewer (JB) then read three studies (27%) that had been preselected by the first two reviewers based on their scores – the lowest score (55%), a middle score (72%) and one of the highest scores (91%). Although the third reviewer was blind to the scores, 100% agreement with the first two reviewers on the scores allocated to each reviewed study was obtained. The critical appraisal scores ranged between 5/11 (55%) to 10/11 (91%). The critical appraisal of all 11 articles revealed an average score of 79%. There were only minor differences in the methodological scores between the remaining 10 articles, which resulted in a high average score. The McMaster tool assisted the reviewers (HdC, AN and JB) to filter out low-scoring articles and guided them to exclude the one study that scored <60% and therefore did not make

November 2017, Print edition

REVIEW

Table 3. Quality score of reviewed articles in chronological order (1997 - 2016) Author/s Hughes and Proctor[24] Bolaños et al.[25] Gordon et al.[26] Chelikh et al.[27] Jackson et al.[28] Woo et al.[29] Johnson[30] Scherer et al.[31] Alvarez et al.[32] Liu[33] Yunusov et al.[34] Average score

Year 1997 2004 2004 2005 2007 2008 2009 2011 2012 2012 2014

1 0 1 1 1 1 1 0 1 1 1 1

2 1 1 1 1 1 0 1 1 1 0 0

3a 1 1 1 1 1 1 1 1 1 0 0

3b 1 1 1 1 1 1 1 0 1 1 1

McMaster questions* 4a 4b 6a 6b 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0

6c 1 1 1 1 1 1 1 1 1 1 1

6d 0 0 0 0 0 0 0 0 0 0 0

7 1 1 1 1 1 1 1 1 1 1 1

Score 8/11 10/11 10/11 9/11 10/11 8/11 8/11 9/11 10/11 8/11 6/11 8.7/11

Percentage 72 91 91 82 91 72 72 82 91 72 55 79

*McMaster questions: 1 = Was the purpose stated clearly? 2 = Was the relevant background literature reviewed? 3a = Was the sample described in detail? 3b = Was the sample size justified? 4a = Were the outcome measures reliable? 4b = Were the outcome measures valid? 6a = Were results reported in terms of statistical significance? 6b = Were the analysis method(s) appropriate? 6c = Was clinical importance reported?; 6d = Were drop-outs reported? 7 = Was the conclusion appropriate, given the study methods and results?

a significant contribution to the review.[35] (Articles with a score of ≥60% were considered satisfactory,[35] so the article that scored 55%[34] was excluded from the review. All the other studies scored between 72% and 91%.) The results of the extracted data will be discussed next.

with TBI included. All 10 of the reviewed studies discussed nystagmus to some degree, although the condition may not have been the main focus of the study. Only a limited number of research studies reported information on nystagmus in patients with TBI, as only 10 studies could be identified for this review.

Results

Participants As determined by the inclusion criteria, all 713 patients had a diagnosis of TBI. They had a wide range of ages (19 - 91 years), with a mean age of 45.6 years; 386 were male and 243 female, with gender not being reported for the remaining 84. No clear difference between the gender groups was reported.

This section presents information in two broad categories, namely the demographics of the study and the PEO components. The data from the PEO components include population (number, age and gender of the patients, as well as TBI diagnosis), exposure (assessment method) and outcome (description of the nystagmus, time to measure the nystagmus and the relationship between nystagmus and TBI). Table 4 sets out a synopsis of the results.

Demographics of the studies

With regard to study demographics, all but one (conducted in 1997) of the 10 studies included were conducted after 2000, with six studies taking place between 2004 and 2009 and three between 2011 and 2012. This can probably be attributed to the development of technologically advanced tools and assessment methods in recent years.[36] As mentioned above, after the passing of the TBI Act in 1996, US federal funds were awarded for developing, expanding and improving access to service delivery for individuals with TBI and their families in the USA, which significantly increased research in this field. Five of the reviewed studies were published in the USA, and one each in Mexico, Israel, France, Korea and China. Of the 10 studies, only two were conducted in LMICs (Mexico and China). This highlights the need for more data from this context, given the high frequency of TBI. There were no obvious trends in the 10 reviewed studies in terms of similar authors or publishing journals, with only two journals (Otology & Neurotology and The Laryngoscope) containing two or more published studies on the topic.

PEO components

The findings of the reviewed studies in terms of PEO components (population, exposure and outcome) will now be discussed in more detail and presented in chronological order (1997 - 2012). The results of the systematic review clearly indicate the lack of comprehensive information about the description of nystagmus in the 713 patients

Exposure ‘Exposure’ in this review refers to the assessment method that was used in evaluating nystagmus in patients with TBI. The assessment method can either be high technology or low technology. High technology refers to computer-based equipment such as a highvelocity/infrared camera or other device to measure and record a patient’s eye movement, specifically nystagmus.[37] High-technology equipment can detect and measure nystagmus as small as one degree per second, which cannot be seen with the naked eye.[38] Low technology includes all bedside assessments to document a patient’s eye movement, such as Frenzel glasses and even questionnaires.[39] Low-technology measures are typically more reliant than high-technology ones on the examiner’s skill and experience in detecting nystagmus. When the nystagmus is too small for the examiner to see with the naked eye, it can easily be missed.[38] In this review, six out of the ten studies relied on low-technology measures to report nystagmus, while only four used high-technology equipment. Although the exact type of equipment was not mentioned, it can be assumed that the results from the high-technology measures would be more accurate than the low-technology (Frenzel glasses or naked eye) assessment of the presence of nystagmus.[40] Of the four studies that utilised high-technology equipment to measure the nystagmus, three were conducted in the USA. Neither of the studies in the LMICs made use of high-technology measures. Outcome The outcomes of the review involved reporting specifically on: (i) the description of nystagmus found in patients with TBI; (ii) the time to

November 2017, Print edition

Chelikh et al.[27] (2005), France

November 2017, Print edition

Range 20 - 57 Mean 40.3 (SD 17.4) ND

Woo et al.[29] (2008), Korea

Johnson[30] (2009), USA Scherer et al.[31] (2011), USA Alvarez et al.[32] (2012), USA Liu[33] (2012), China

228 M, 219 F ND

23 M, 1 F

2 M, 1 F

Yes

Low tech

High tech

Low tech

Primary

Primary Gaze

Primary

Yes

Low tech

Eye position Primary

TBI dx Exposure* Yes Low tech

BPPN

Spontaneous Gaze

BPPN

Spontaneous BPPN

BPPN

Optokinetic

Type Position induced

Up-beating Torsional Downbeat Vertical ND

Geotropic or ageotropic (depending on canal involvement) Left-beating

Rotatory upbeat Left-beating horizontal Paroxysmal

Up-beating Torsional

Intensity Direction ND Vertical Horizontal Torsional ND Vertical

Description of the nystagmus

Yes

Relationship between nystagmus and TBI ND

Within 3 months after ND occurrence of TBI

Nystagmus disappeared within 7 days ND

Secondary BPPV as result of TBI is more difficult to treat than idiopathic BPPV Horizontal nystagmus Head trauma is directly disappeared 4 weeks responsible for vertigo. Intensity after TBI; symptom of TBI did not correlate with the free after 3 weeks intensity of the symptoms in this case ND Statistically, the anterior semicircular canal is the main cause of BPPV in TBI

60% had complete recovery during the first 6 months 3 days post-trauma

Time to measure Fixation nystagmus No ND

Outcome

TBI = traumatic brain injury; dx = diagnosis; M = male; F = female; ND = not discussed; SD = standard deviation; BPPN = benign paroxysmal positional nystagmus; BPPV = benign paroxysmal positional vertigo. *Assessment method (high or low tech).

557

Jackson et al.[28] (2007), USA

Mean 61 (range 27 - 91)

19, 49, 51

Mean 56.3 (SD 15.6)

Gordon et al.[26] (2004), Israel

10 M, 11 F

Age (years) Gender Mean 52.3 12 M, 10 F (range 22.5 - 76.8) Mean 29.8 ND (SD 11.2)

Study (author (year), country) N 22 Hughes and Proctor[24] (1997), USA 5 BolaĂąos et al.[25] (2004), Mexico

Participants

Table 4. Population, exposure and outcome (PEO)

REVIEW

measure nystagmus after the TBI incident; and (iii) the relationship between the severity of the TBI and the degree of nystagmus. Description of the nystagmus The nystagmus found in patients with TBI was categorised according to eye position, type of nystagmus, intensity of the nystagmus, direction of the nystagmus and whether it was measured with or without fixation. A primary (centre) eye position was reported in nine out of the ten studies, with one study reporting both primary and gaze-related eye positions. Only one study did not report on the patient’s eye position during testing. The position of the eye while measuring nystagmus is important, as it can indicate different pathologies based on when the nystagmus was evoked. The type of nystagmus in these reviews varied greatly and no single type could be identified. Two studies reported two separate types of nystagmus observed in the participants. The results included benign paroxysmal positional nystagmus (n=4), spontaneous nystagmus (n=42), position-induced nystagmus (n=41), optokinetic nystagmus (n=41) and gaze-evoked nystagmus (n=41). The remaining three studies did not report on the type of nystagmus observed or evoked during assessment. The intensity of nystagmus is measured in degrees per second.[40] This is only possible when high-technology equipment is used.[38] Although four of the studies reported using high-technology equipment, none reported on the intensity or degree of nystagmus found in the patients with TBI. Only three studies reported on the presence of fixation during testing, with only one study using fixation and the remaining two testing without the presence of a fixation point. Time to measure the nystagmus The best time to measure nystagmus after the TBI incident was explored in this section. It is important to know the best time to measure the nystagmus, as the symptoms can vary and disappear altogether over time.[15] Of the 10 studies reviewed, five did not discuss the best time to measure nystagmus after TBI. The studies that did discuss it reported varying data, ranging from 3 days after trauma to a complete recovery in most patients within 6 months.

The type of equipment used for measuring and assessing nystagmus is important for the outcome of the review, as only high-technology equipment can measure its intensity.[38] In some cases, where the intensity of the nystagmus is very low, low-technology assessment methods can also not determine its direction.[39] The fact that lowtechnology measures were used in most of the reviewed studies could explain the lack of data on the intensity of the nystagmus. Determining the direction of nystagmus can assist in differentially diagnosing a patient. It is important to note the direction (or change in direction) of the nystagmus, as this can be indicative of specific abnormalities. If the patient has a low-intensity nystagmus, lowtechnology equipment would not be able to detect or assess the direction of the nystagmus, which could lead to inaccurate data. In the 10 reviewed studies, no single direction of nystagmus was observed and the reported directions of the nystagmus included vertical, horizontal and rotatory (torsional) nystagmus, as well as up-beating, down-beating, left-beating and right-beating nystagmus. When measuring nystagmus, it is important to know whether it is present with or without a fixation point. This will assist in determining whether the lesion is central or peripheral in nature. Most peripheral lesions can result in nystagmus that can be suppressed with fixation, whereas central lesions usually result in nystagmus that is present even with fixation. Should nystagmus not be measured early in the evaluation, it could be missed and remain undocumented.[41] No clear indication of when nystagmus should be measured was obtained from this review. An important recommendation noted in this review (from Scherer et al.[31]) was that although some patients may appear to be asymptomatic, 30% of these asymptomatic patients had abnormal vestibular findings and nystagmus. Vestibular testing confirms a higher incidence of vestibular and oculomotor dysfunction in patients with blast-related TBI than in asymptomatic patients. The review also highlighted the lack of data describing the measurement and assessment of nystagmus in patients with TBI and indicated the need for high-technology measures to be used when assessing these patients. Use of high-technology equipment could aid in the documentation of nystagmus in patients with TBI, which would lead to more accurate diagnosis and management.[37,38]

Relationship between nystagmus and TBI In this section the focus was on trying to establish whether there was any relationship between the intensity of the nystagmus and the severity of the TBI. Seven of the ten studies did not discuss this relationship, while of the remaining three studies, one indicated that traumatic BPPV is more difficult to treat than idiopathic BPPV. The other two studies provided important data about this relationship: one[27] indicated that head trauma was directly responsible for vertigo and that the intensity of TBI did not correlate with the intensity of symptoms/nystagmus in this case, while the other[28] mentioned that, statistically speaking, the anterior semicircular canal is the main cause of BPPV in TBI. The results of the review indicated a lack of comprehensive data regarding the assessment and measurement of nystagmus in TBI patients, as well as on the possible link and relationship between nystagmus and TBI.

Limitations of this review

Discussion

Recommendations and conclusion

In this systematic review, 10 articles were reviewed to compile information regarding nystagmus in patients with TBI. The review indicated that most components related to nystagmus – especially its description and measurement in patients with TBI – are not well documented.

The findings that emerged from this review are limited to the primary purpose of this research, which was to use a systematic review with a multiple perspective to describe and analyse the literature that examined articles describing nystagmus in patients with TBI from 1996 to 2016, and generalisations therefore cannot be made outside this context. The overall approach to this review was strengthened by the development of an a priori protocol and adherence to the PRISMA statement.[42] Other shortcomings of the review are that only studies in English and only peer-reviewed studies that were available online were considered for inclusion – clinical case reports, lecture or conference notes, books, theses or other unpublished literature were therefore not considered. Furthermore, the review question and subsequent search terms did not specifically include rehabilitation or intervention studies.

This systematic review indicated that, with regard to patients with chronic recurrent vertigo after TBI: • There is a growing body of evidence that BPPV should be considered during the medical examination of all patients suffering from head trauma.[30]

November 2017, Print edition

REVIEW

• All patients with TBI should undergo visual (eye movement) and vestibular examination. • Future studies should include quantitative measurements of eye movements and nystagmus.[32] Furthermore, it is recommended that a paediatric sample should be included in the participant group, and that studies should be conducted with high-technology assessment methods to report on the intensity and direction of the nystagmus observed in patients with TBI. In conclusion, there is a lack of evidence regarding the description of nystagmus in patients with TBI, and more research is needed – specifically on using high-technology equipment to report on the eye position, type, intensity, direction and fixation of nystagmus. Information is also needed on the optimal time for measuring nystagmus in patients with TBI and on the possible relationship between the intensity of the nystagmus and the severity of the TBI. This information would enable clinicians to obtain a better understanding of the importance of correct measurement of nystagmus in TBI patients, which could improve their care and diagnosis, as well as their quality of life. Acknowledgements. None. Author contributions. All three authors were equally involved in the production of the article and read the final manuscript. Funding. None. Conflicts of interest. None. 1. Akin FW, Murnane OD. Head injury and blast exposure: Vestibular consequences. Otolaryngol Clin North Am 2011;44(2):323-334. https://doi.org/10.1016/j.otc.2011.01.005 2. Lucas S, Hoffman JM, Bell KR, Dikmen S. A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia 2014;34(2):93-102. https://doi. org/10.1177/0333102413499645 3. Bryan-Hancock C, Harrison J. The global burden of traumatic brain injury: Preliminary results from the Global Burden of Disease Project. Inj Prev 2010;16:17. https://doi.org/10.1136/ip.2010.029215.61 4. Jury MA, Flynn MC. Auditory and vestibular sequelae to traumatic brain injury: A pilot study. N Z Med J 2001;114(1134):286-288. https://www.ncbi.nlm.nih.gov/pubmed/11480511 (accessed 10 October 2017). 5. Ruff RL, Riechers RG, Wang XF, Piero, T, Ruff SS. A case-control study examining whether neurological deficits and PTSD in combat veterans are related to episodes of mild TBI. BMJ Open 2012;2(2):1-12. https://doi.org/10.1136/bmjopen-2011-000312 6. Naidoo D. Traumatic brain injury: The South African landscape. S Afr Med J 2013;103(9):613-614. https://doi.org/10.7196/SAMJ.7325 7. National Institute of Occupational Health, South Africa. Traumatic brain injury (head injuries) – World Head Injury Awareness. National Health Laboratory Service: Topical Issues. http://www.noioih.ac.za/?pa ge=topical&id=13&rid=214 (accessed 23 November 2016). 8. Pretorius C, Broodryk M. Misconceptions about traumatic brain injuries among South African university students. S Afr J Psychiatry 2013;19(3):75-79. https://doi.org/10.7196/SAJP.436 9. Arciniegas DB, Held K, Wagner P. Cognitive impairment following traumatic brain injury. Curr Treat Options Neurol 2002;4(1):43-57. https://doi.org/10.1007/s11940-002-0004-6 10. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010;34(2):87-93. https://doi.org/10.1097/NPT.0b013e3181dde568 11. Hoffer ME, Gottshall KR, Moore R, Balough BJ, Wester D. Characterizing and treating dizziness after mild head trauma. Otol Neurotol 2004;25(2):135-138. https://doi.org/10.1097/00129492-200403000-00009 12. McLeod TCV, Hale TD. Vestibular and balance issues following sport-related concussion. Brain Inj 2015;29(2):175-184. https://doi.org/10.3109/02699052.2014.965206 13. Lueck CJ. Nystagmus. Pract Neurol 2005;5(5):288-291. http://pn.bmj.com/content/5/5/288 (accessed 10 October 2017).

14. Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. Philadelphia: Lippincott, Williams & Wilkins, 2001:75-91. https://doi.org/10.1097/01253086-199620010-00023 15. Hanes DA, McCollum G. Cognitive-vestibular interactions: A review of patient difficulties and possible mechanisms. J Vestib Res 2006;16(3):25-91. https://www.ncbi.nlm.nih.gov/pubmed/17312336 (accessed 10 October 2017). 16. Cuschieri A. Anatomy of the peripheral and central vestibular system. Capsula Eburnea 2009;4(16):11-24. https://doi.org/10.3269/1970-5492.2009.4.16 17. Khan S, Chang R. Anatomy of the vestibular system: A review. NeuroRehabilitation 2013;32(3):437-443. https://doi.org/10.3233/NRE-130866 18. Brennan M. Visual-vestibular interaction and treatment of dizziness: A case report. J Behav Optom 2012;23(3):68-72. https://www.oepf.org/journal/pdf/jbo-volume-23-issue-3-visual-vestibular-interactionand-treatment-dizziness-case-report (accessed 10 October 2017). 19. Hain TC, American Hearing Research Foundation. Post-traumatic vertigo. http://american-hearing.org/ disorders/post-traumatic-vertigo/ (accessed 25 November 2016). 20. Basford JR, Chou L, Kaufman KR, et al. An assessment of gait and balance deficits after traumatic brain injury. Arch Phys Med Rehabil 2003;84(3):343-349. https://doi.org/10.1053/apmr.2003.50034 21. Labuguen RH. Initial evaluation of vertigo. Am Fam Physician 2006;73(2):244-251. https://www.ncbi. nlm.nih.gov/pubmed/16445269 (accessed 10 October 2017). 22. Stahl JS, Leigh RJ. Nystagmus. Curr Neurol Neurosci Rep 2001;1(5):471-477. https://doi.org/10.1007/ s11910-001-0109-4 23. Law M, Stewart D, Pollock N, Letts L, Bosch J, Westmorland M, McMaster University. Critical Review Form – Qualitative Studies (Version 2.0) Ontario: McMaster University, 2007. https://www.canchild.ca/ system/tenon/assets/attachments/000/000/359/original/qualform.pdf (accessed 10 October 2017). 24. Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope 1997;107(5):607-613. https://doi.org/10.1097/00005537-199705000-00010 25. Bolaños I, Lozano D, Cantú C. Internuclear ophthalmoplegia: Causes and long-term follow-up in 65 patients. Acta Neurol Scand 2004;110(3):161-165. https://doi.org/10.1111/j.1600-0404.2004.00278.x 26. Gordon CR, Levite R, Joffe V, Gadoth N. Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form? Arch Neurol 2004;61(10):1590-1593. https://doi.org/10.1001/ archneur.61.10.1590 27. Chelikh L, Timoshenko AP, Bertholon P, Tringali S, Martin C. Combined horizontal and posterior canal benign paroxysmal positional vertigo in three patients with head trauma. Ann Otol Rhinol Laryngol 2005;114(2):105-110. https://doi.org/10.1177/000348940511400204 28. Jackson LE, Morgan B, Fletcher JC, Krueger WWO. Anterior canal benign paroxysmal positional vertigo: An underappreciated entity. Otol Neurotol 2007;28(2):218-222. https://doi.org/10.1097/01. mao.0000247825.90774.6b 29. Woo H, Song S, Kim Y, Bai CH. Pneumolabyrinth without temporal bone fracture: Different outcomes for hearing recovery. Laryngoscope 2008;118(8):1464-1466. https://doi.org/10.1097/ MLG.0b013e318172ab03 30. Johnson EG. Clinical management of a patient with chronic recurrent vertigo following a mild traumatic brain injury. Case Rep Med 2009 (2009), Article ID 910596. https://doi.org/10.1155/2009/910596 31. Scherer MR, Burrows H, Pinto R, et al. Evidence of central and peripheral vestibular pathology in blast-related traumatic brain injury. Otol Neurotol 2011;32(4):571-580. https://doi.org/10.1097/ MAO.0b013e318210b8fa 32. Alvarez TL, Kim EH, Vicci VR, Dhar SK, Biswal BB, Barrett AM. Concurrent vision dysfunctions in convergence insufficiency with traumatic brain injury. Optom Vis Sci 2012;89(12):1740-1751. https://doi. org/10.1097/OPX.0b013e3182772dce 33. Liu H. Presentation and outcome of post-traumatic benign paroxysmal positional vertigo. Acta Otolaryngol 2012;132(8):803-806. https://doi.org/10.3109/00016489.2012.657359 34. Yunusov F, Park J, Huh YE, Kim H, Kim J. Mystery case: Pendular see-saw nystagmus as a delayed complication of traumatic brain injury. Am Acad Neurol 2014;82(4):147-148. https://doi.org/10.1212/ WNL.0000000000000358 35. Audet N, Gagnon R, Ladouceur R, Marcil M. How effective is the teaching of critical analysis of scientific publications? Review of studies and their methodological quality. CMAJ 1993;148(6):945-952. https:// www.ncbi.nlm.nih.gov/pubmed/8448709 (accessed 10 October 2017). 36. Ferreiro G, Carda S, Moslavac S, Rabini A. Technological advances in instrument assessment and rehabilitation. Biomed Res Int 2015 (2015), Article ID 264067. https://doi.org/10.1155/2015/264067 37. Manso A, Gananca MM, Caovilla HH. Vestibular rehabilitation with visual stimuli in peripheral vestibular disorders. Braz J Otorhinolaryngol 2016;82(2):232-241. https://doi.org/10.1016/j.bjorl.2015.05.019 38. Yao J, Tai Z, Yin Z. A new measure of nystagmus acuity. Int J Ophthalmol 2014;7(1):95-99. https://doi. org/10.3980/j.issn.2222-3959.2014.01.17 39. Blohm A. A survey of audiologists’ clinical practices and their formal education and training in the assessment and management of adults with vestibular pathologies. AuD thesis, Department of Audiology, Speech-Language Pathology and Deaf Studies, Towson University, Md., 2013. 40. Miles RD, Zapala DA. Vestibular function measurement devices. Semin Hear 2015;36(1):49-74. https:// doi.org/10.1055/s-0034-1396926 41. Jacobson GP, Shephard NT. Balance Function Assessment and Management. 2nd ed. San Diego, Calif.: Plural Publishing, 2014. 42. Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med 2009;141(4):264-269. https://doi. org/10.1371/journal.pmed.1000097

Accepted 8 June 2017.

November 2017, Print edition

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

RESEARCH

Beyond clinical trials: Cross-sectional associations of combination antiretroviral therapy with reports of multiple symptoms and non-adherence among adolescents in South Africa H P M Natukunda,1,2 MPhil; L D Cluver,2,3 DPhil; E Toska,2,4 DPhil; V Musiime,5,6 PhD; A R Yakubovich,2 MSc Pathology Department, Medical Research Council, Harwell Institute, UK Department of Social Policy and Intervention, University of Oxford, UK 3 Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa 4 AIDS and Society Research Unit, Centre for Social Science Research, Faculty of Humanities, University of Cape Town, South Africa 5 Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda 6 Joint Clinical Research Centre, Kampala, Uganda 1 2

Corresponding author: H P M Natukunda (h.natukunda@har.mrc.ac.uk) Background. Studies investigating symptoms associated with combination antiretroviral therapy (cART) use among adolescents in resource-limited settings are rare beyond clinical trials. Identifying adolescents at risk of non-adherence is imperative for HIV/AIDS programming and controlling the epidemic in this key population. Objective. To examine which cART regimens were associated with reports of multiple symptoms and past-week non-adherence in a large community-traced sample of HIV-positive adolescents in South Africa (SA). Methods. A total of 1 175 HIV-positive ART-experienced adolescents aged 10 - 19 years attending 53 health facilities in the Eastern Cape Province, SA, were interviewed in 2014 - 2015. Ninety percent (n=1 059) were included in the study. Adolescents who reported no medication use and those with unclear or missing data were excluded from further analysis, resulting in a sample for analysis of n=501. Outcomes were reports of multiple symptoms (three or more symptoms in the past 6 months) and past-week ART non-adherence (<95% correct doses in the past week). Multivariable logistic regression analyses controlled for sociodemographic and HIV-related covariates in Stata 13/IC. Results. Of the adolescents included, 54.3% were female. The median age was 14 (interquartile range 12 - 16) years, and 66.5% were vertically infected. The prevalence of multiple symptoms was 59.7% (95% confidence interval (CI) 55.3 - 63.9). Independent of covariates, stavudine (d4T)-containing cART regimens and the fixed-dose combination of tenofovir (TDF) + emtricitabine (FTC) + efavirenz (EFV) were associated with more reports of multiple symptoms (adjusted odds ratio (aOR) 3.38; 95% CI 1.19 - 9.60 and aOR 2.67; 95% CI 1.21 5.88, respectively). Lopinavir/ritonavir (LPV/r)-containing regimens were associated with fewer reports of multiple symptoms (aOR 0.47; 95% CI 0.21 - 1.04). For EFV-based regimens, adolescents on d4T + lamivudine (3TC) + EFV were more likely to report multiple symptoms than those on TDF + FTC + EFV or those on abacavir (ABC) + 3TC + EFV (aOR 3.26; 95% CI 1.01 - 10.52, aOR 2.86; 95% CI 1.35 - 6.05 and aOR 1.08; 95% CI 0.64 - 1.82, respectively). However, only TDF + FTC + EFV cART was associated with lower levels of non-adherence among participants (aOR 0.44; 95% CI 0.21 - 0.93). Conclusions. Rates of multiple symptoms among HIV-positive ART-experienced adolescents were high. d4T-containing regimens and TDF + FTC + EFV were associated with more reports of multiple symptoms, whereas LPV/r-containing regimens were associated with fewer reports. However, adolescents on TDF + FTC + EFV were the most adherent subgroup. These findings support the World Health Organization-recommended discontinuation of d4T use, but also underscore the dilemma faced by clinicians when choosing between lowtoxicity regimens and those that promote ART adherence, particularly among HIV-positive adolescents. S Afr Med J 2017;107(11):965-975. DOI:10.7196/SAMJ.2017.v107i11.12405

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12405

November 2017, Print edition

RESEARCH

Sensory integration intervention and the development of the premature infant: A controlled trial E Lecuona,1 M (Occupational Therapy); A van Jaarsveld,2 M (Occupational Therapy); J Raubenheimer,3 PhD; R van Heerden, M (Occupational Therapy), PhD epartment of Occupational Therapy, Universitas Academic Hospital, Bloemfontein, South Africa (current affiliation: occupational therapy D private practice, Bebe Developmental Care, Cape Town, South Africa) 2 Department of Occupational Therapy, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa 3 Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa (current affiliation: Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Australia) 4 Occupational therapy private practice, Bloemfontein, South Africa 1

Corresponding author: E Lecuona (elise@bebedevelopmentalcare.co.za) Background. Premature infants are at risk of sensory processing difficulties and developmental delays due to an immature central nervous system and possible episodes of medical instability, discomfort, pain and stress during the first weeks or months after birth. Objective. To investigate the effect of Ayres Sensory Integration (ASI) on the development of premature infants in the first 12 months of life. Methods. A pre-/post-test experimental design was used to randomly divide 24 premature infants from a low socioeconomic setting in Bloemfontein, South Africa, into experimental and control groups after being matched by corrected age and gender. Developmental status was determined with the Bayley III Scales of Infant and Toddler Development, the Test of Sensory Functions in Infants and the Infant/ Toddler Sensory Profile. The experimental group received 10 weeks of ASI intervention. Results. ASI intervention had a positive effect on the sensory processing and development of premature infants, especially in terms of cognitive, language and motor development. Conclusions. ASI intervention at an early age enhances the developmental progress of premature infants. S Afr Med J 2017;107(11):976-982. DOI:10.7196/SAMJ.2017.v107i11.12393

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12393

Extraspinal osteoarticular multidrug-resistant tuberculosis in children: A case series G B Firth,1 MB BCh, FCS (Orth), MMed (Orth); J Lescheid,1 BSc, MD, FRCSC; M Camacho,1 MB BCh; M Esteves,1 BCMP; N Beylis,2 MB BCh; M J Groome,3,4 MB BCh, MSc, PhD; S A Madhi,3,4 MB BCh, FCPaeds (SA), PhD ¹ Division of Orthopaedic Surgery, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ² National Health Laboratory Service, Mycobacteriology Referral Laboratory, Braamfontein, Johannesburg, South Africa ³ Medical Research Council Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa 4 Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: M J Groome (groomem@rmpru.co.za) Background. South Africa (SA) is known to have a high disease burden of tuberculosis (TB). Extraspinal osteoarticular multidrug-resistant tuberculosis (ESOA MDR-TB) in children has only been described in a few case reports worldwide. Objectives. To describe the epidemiology and highlight the potential problem of ESOA MDR-TB infections as seen in children from a single academic hospital in SA.

November 2017, Print edition

RESEARCH

Methods. A retrospective record review was performed on all children diagnosed with ESOA TB infection at Chris Hani Baragwanath Academic Hospital, Johannesburg, between 1 January 2006 and 31 December 2015. All patients with a positive TB culture (fluid or tissue) from the surgical site of biopsy (bone or joint) and who were hospitalised were included. Organism culture and drug sensitivity testing were performed. Results. Overall 19 cases of ESOA TB were identified. Areas involved included the shoulder (2 cases), elbow (2 cases), hip (7 cases), knee (4 cases), ankle (3 cases) and humerus (1 case). The mean age of the population was 7.7 (range 2.0 - 14.0) years. The mean white cell count was 11.3 (range 5 - 28.9) × 109/L, the mean C-reactive protein level 53.8 (range 1.0 - 364.0) mg/L and the mean erythrocyte sedimentation rate 35.5 (range 4.0 - 85.0) mm/h. Two cases (10.5%) were MDR, and a further case (5.3%) was resistant to isoniazid only. Four of 12 patients tested positive for HIV. One of the HIV-positive patients was isoniazid resistant. The two positive ESOA MDR-TB cases are discussed in detail. Conclusions. These findings indicate that ESOA MDR-TB is a reality in this paediatric population (10.5%) and a high index of suspicion should be maintained, especially when cultures are negative in children with signs and symptoms of ESOA TB. The effect of HIV infection on the incidence of ESOA MDR-TB requires further study. S Afr Med J 2017;107(11):983-986. DOI:10.7196/SAMJ.2017.v107i11.12577

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12577

Impact of the learning environment on career intentions of paediatric interns K L Naidoo,1 MB ChB, DCH, FC Paed (SA); J M van Wyk,2 BSc (Ed), BEd, MEd, PhD; M Adhikari,1,3 MB ChB, FCP (Paed) (SA), PhD epartment of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, D University of KwaZulu-Natal, Durban, South Africa 2 Department of Clinical and Professional Practice, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 3 Postgraduate Office, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 1

Corresponding author: K L Naidoo (naidook9@ukzn.ac.za) Background. High childhood disease burdens in South Africa (SA) prioritise the need for careers in paediatrics. Experiences of junior doctors during internship may influence career trajectories in a direction that is discordant with national health priorities. Objective. To explore the influence of the learning environment and demography on career intentions of SA paediatric interns. Methods. This cross-sectional study involved sampling intern groups at the start and completion of internship in paediatrics to determine their career intentions. A validated version of the Postgraduate Hospital Educational Environmental Measure was used to measure perceptions of the learning environment (LE) in the post-paediatric internship cohort. Measures of the LE in combination with demographic factors were compared with career intentions. Associations were determined by t-tests or analysis of variance and χ2 tests. Results. A total sample size of 422 was obtained from two separate cohorts, which were demographically similar except for age. Most interns (88.4%) intended to remain in SA, with 72.6% indicating an intention to practise in the public healthcare sector. There was a high intention to specialise (85.9%), and 60.2% were keen on a career that involved children. Previous educational exposure and demographic factors other than gender did not significantly influence career intentions. Perceptions of the LE significantly influenced decisions to stay in SA’s public sector and to care for children. The decision to specialise, however, was not influenced by demographic variables or perceptions of the LE. Conclusions. Paediatric interns from diverse sociocultural and educational backgrounds had similar career intentions. Most interns were keen to work with children in SA’s public sector. However, learning experiences during internship significantly influence these intentions and have the potential to drive young doctors away from SA, its public health service and paediatric care. Ensuring that training and support of interns are optimised is essential if SA is to align its healthcare needs with the aspirations of its future healthcare workers. S Afr Med J 2017;107(11):987-993. DOI:10.7196/SAMJ.2017.v107i11.12589

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12589

November 2017, Print edition

RESEARCH

Access to and utilisation of healthcare services by sex workers at truck-stop clinics in South Africa: A case study S C Fobosi,1 MA; S T Lalla-Edward,1 MA; S Ncube;1 F Buthelezi;1 P Matthew;2 A Kadyakapita,2 MD; M Slabbert,1 MBA; C A Hankins,3,4 MD, PhD; W D F Venter,1 MD; G B Gomez,3,5 PhD Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa North Star Alliance, Durban, South Africa 3 Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Centre, University of Amsterdam, The Netherlands 4 Department of Epidemiology, Biostatistics, and Occupational Health, Faculty of Medicine, McGill University, Montreal, Canada 5 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK 1 2

Corresponding author: S T Lalla-Edward (slalla-edward@wrhi.ac.za) Background. Sex worker-specific health services aim to respond to the challenges that this key population faces in accessing healthcare. These services aim to integrate primary healthcare (PHC) interventions, yet most services tend to focus on prevention of HIV and sexually transmitted infections (STIs). North Star Alliance (North Star) is a public-private partnership providing a healthcare service package in roadside wellness clinics (RWCs) to at-risk populations along transport corridors in sub-Saharan Africa. Objectives. To inform future service development for sex workers and describe North Starâ&#x20AC;&#x2122;s contribution to healthcare provision to this population in South Africa, we describe services provided to and utilised by sex workers, and their views of these services. Methods. Using a mixed-methods approach, we present quantitative analyses of anonymised North Star routine data for sex workers for October 2013 - September 2015, covering nine sites in seven provinces. Clinic visits were disaggregated by type of service accessed. We performed thematic analysis of 25 semi-structured interviews conducted at five clinics. Results. A total of 2 794 sex workers accessed RWCs during the 2 years. Sex workers attending clinics were almost exclusively female (98.2%) and aged <40 years (83.8%). The majority were South African (83.8%), except at Musina, where the majority of clients were Zimbabwean. On average, sex workers visited the clinics 1.5 times per person. However, in most cases only one service was accessed per visit. PHC services other than for HIV and STIs were accessed more commonly than HIV-specific services and STI treatment. There was an increase in the number of services accessed over time, the figure almost doubling from 1 489 during the first year to 2 936 during the second year. Although during recruitment participants reported having had sex in exchange for goods or money during the past 3 months, not all participants selfidentified as sex workers during interviews; however, all reported feeling at higher risk of poor health than the general population owing to their involvement in sex work. Participants reported satisfaction with site accessibility, location and operating hours. Sex workers accessing sites described services as being suitable and accessible, with friendly staff. Conclusions. RWCs were highly appreciated by the users, as they are suitable and accessible. The sex workers who used the clinics visited them irregularly, mostly for PHC services other than HIV and STIs. Services other than the one for which the sex worker came to the clinic rarely appeared to be offered. We recommend areas for service expansion. S Afr Med J 2017;107(11):994-999. DOI:10.7196/SAMJ.2017.v107i11.12379

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12379

November 2017, Print edition

RESEARCH

Vulvar cancer is not a disease of the elderly: Treatment and outcome at a tertiary referral centre in South Africa J L Butt, MB ChB, FCOG (SA), MMed, Cert Gynaecological Oncology (SA); M H Botha, MB ChB, FCOG (SA), Cert Gynaecological Oncology (SA), PhD Department of Obstetrics and Gynaecology, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: J Butt (jbutt@sun.ac.za) Background. An increase in vulvar cancer in young women is attributed to infection with oncogenic human papillomavirus (HPV). South Africa (SA) has a high prevalence of HPV, and it was therefore hypothesised that women with vulvar cancer here would be younger than in high-income countries (HICs). Objective. To describe age, cancer stage, treatment and outcome of patients with vulvar cancer at a tertiary referral centre in SA. Methods. In a retrospective observational study, patient records of women diagnosed with vulvar cancer between 2001 and 2014 were reviewed and demographic and surgical details captured. Histology results of vulvar biopsies and resected specimens were checked for HPV changes, koilocytes and usual-type vulval intraepithelial neoplasia. Patients were restaged using the International Federation of Gynecology and ObstetricsÂ (FIGO) 2009 staging system to allow for comparison of outcomes. Five-year disease-specific survival probability curves were generated using Kaplan-Meier analysis. Results. The mean age of the 180 patients in the study was 52.5 years. Those who had documented HPV changes on histological specimens had a mean age of 50.4 years. More than 50% of the patients had advanced-stage disease, and 62.7% were treated with primary surgery. Five-year disease-specific survival probabilities were similar to those reported in the literature. Conclusions. Vulvar cancer should not be regarded as a disease of the elderly in SA, as women with vulvar cancer are 10 - 15 years younger than in HICs. A large proportion of patients present with advanced-stage disease. Health professionals should be alert to vulvar lesions, especially in women with abnormal Pap smears, to reduce the morbidity and mortality of this disease. S Afr Med J 2017;107(11):1000-1004. DOI:10.7196/SAMJ.2017.v107i11.12497

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12497

Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in South Africa T S Maswime,1 MB ChB, FCOG (SA), MMed, PhD; E Buchmann,2 MB BCh, FCOG (SA), MSc, PhD 1 2

its Obstetrics and Gynaecology Clinical Research Division, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa W Department of Obstetrics and Gynaecology, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: T S Maswime (tumishang.maswime@wits.ac.za) Background. A rising caesarean section rate and substandard peri-operative care are believed to be the main reasons for recent increases in maternal deaths from bleeding during and after caesarean section (BDACS) in South Africa (SA). The Donabedian model assumes that clinical outcomes are influenced by healthcare workers and the healthcare system. Objectives. To evaluate near-miss cases from BDACS with regard to health system structure (resources and facilities) and process (patient care). Methods. A cross-sectional prospective study was conducted in greater Johannesburg, SA. Data of women who had near-miss-related BDACS were collected by means of ongoing surveillance at 13 public hospitals. The World Health Organization intervention criteria were used to identify near-miss cases. A comparison of structure and process between the healthcare facilities was conducted.

November 2017, Print edition

RESEARCH

Results. Of 20 527 caesarean sections , there were 93 near misses and 7 maternal deaths from BDACS. Dominant risk factors for near misses were previous caesarean section (43.9%), anaemia (25.3%) and pregnancy-induced hypertension (28.6%). Eighteen women were transferred to higher levels of care, and 8 (44.4%) experienced transport delays of >1 hour. The caesarean section decision-to-incision interval (DII) was ≥60 minutes in 77 of 86 women, with an average interval of 4 hours. Structural deficiencies were frequently present in district hospitals, and there were serious delays in ambulance transfer and DIIs at all levels of care. Conclusion. The majority of the women had risk factors for BDACS. There were major ambulance delays and lack of facilities, mostly in district hospitals. All women required life-saving interventions, but could not access appropriate care timeously. Prevention and management of BDACS require a fully functional health system. S Afr Med J 2017;107(11):1005-1009. DOI:10.7196/SAMJ.2017.v107i11.12340

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12340

Cost awareness among healthcare professionals at a South African hospital: A cross-sectional survey G D Nethathe,1,2 MB ChB, DA (SA), FCA (SA), MMed (Anaes), FANZCA, Cert Crit Care (SA), PGDip Health Science Education; S Tshukutsoane,2 BCur Hons; K J Denny,3 PhD, MBBS, BSc epartment of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane; and Faculty of Medicine, D University of Queensland, Brisbane, Australia 2 Division of Critical Care, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, Australia 1

Corresponding author: G D Nethathe (gladness.nethathe@wits.ac.za) Background. Financial cost is a recognised cause of lack of access to adequate healthcare in South Africa (SA). Data describing the SA healthcare professional (HCP)’s awareness of costs are scant. Their increased awareness of healthcare costs may improve efficacy and reduce wasteful expenditure. Objective. To assess SA HCP’s knowledge of healthcare costs, identify factors that influence cost awareness, and to determine if surveyed HCPs received training related to cost management during their studies or at any stage during their practice. Methods. This cross-sectional survey was conducted by means of a standardised questionnaire. HCPs working at a major tertiary academic hospital were asked to answer an anonymous standardised questionnaire aimed at determining their awareness of the costs of commonly requested hospital items and tests. Cost accuracy was determined by assessing the log deviation of the estimated cost from true cost, with values >0 and <0 representing overestimates and underestimates, respectively. Cost estimations were considered correct if the absolute value of the log deviation was <0.2. Participants’ attitudes towards the potential impact of the availability of cost information on their practice were assessed. Results. The overall cost estimation of accuracy was low (mean 0.60; standard deviation 1.99) and differed widely between items. Cheaper items were more likely to be overestimated and expensive items to be underestimated. The majority of participants indicated that cost awareness education was not part of their training or practice (84.5%) and that they would like cost information to be made readily available (92.2%). Eighty-four percent of participants were of the opinion that cost information would not negatively affect patient care. Conclusion. The use of percentage deviation from true cost as a method of assessing cost awareness creates a bias towards overestimation, which is more relevant for cheap items, as larger overestimates are more common for these items. We propose the use of log deviation of the estimated cost from the true cost as a method of assessing cost estimation accuracy. HCPs have a limited understanding of the costs of disposables, tests and drugs commonly used in their practice and would prefer that cost information be made readily available to them. Attention should be paid to improving cost awareness among HCPs working at SA hospitals. S Afr Med J 2017;107(11):1010-1014. DOI:10.7196/SAMJ.2017.v107i11.12513

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12513

November 2017, Print edition

RESEARCH

Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XL-MAC system M Wells, MB BCh, MSc (Med) (Emergency Medicine), FCEM (SA); L N Goldstein, MB BCh, MMed (Emergency Medicine), FCEM (SA), Cert Critical Care (SA); A Bentley, MB BCh, PhD Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: M Wells (mike.wells@emergencymedicine.co.za) Background. Erroneous weight estimation during the management of emergency presentations in children may contribute to patient harm and poor outcomes. The PAWPER (Paediatric Advanced Weight Prediction in the Emergency Room) XL tape is an accurate length-based, habitusmodified weight estimation device, but is vulnerable to errors if subjective visual assessments of childrenâ&#x20AC;&#x2122;s body habitus are incorrect or erratic. Objective. Mid-arm circumference (MAC) has previously been used as a surrogate indicator of habitus, and the objective of this study was to determine whether MAC cut-off values could be used to predict habitus scores (HSs) to create an objective and standardised weight estimation methodology, the PAWPER XL-MAC method. Methods. The PAWPER XL-MAC model was developed by creating MAC ranges for each HS in each weight segment of the tape. This model was validated against two samples, the National Health and Nutrition Examination Survey datasets and data from two previous PAWPER tape studies. The primary outcome measure was to achieve >70% of estimations within 10% of measured weight (PW10 >70%) and >95% within 20% of measured weight (PW20 >95%) for children aged 0 - 18 years. Results. The PAWPER XL-MAC model achieved very high accuracy in the three validation datasets (PW10 79.2%, 79.0% and 81.9%) and a very low critical error rate (PW20 98.5%, 96.0% and 98.0%). This accuracy was maintained across all ages and in all habitus types, except for the severely obese. Conclusions. The PAWPER XL-MAC model proved to be a very accurate, fully objective, standardised system in this study. It has the potential to be accurate across a wide variety of populations, even when used by those not experienced in visual assessment of habitus. S Afr Med J 2017;107(11):1015-1021. DOI:10.7196/SAMJ.2017.v107i11.12505

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12505

Endoscopy services in KwaZulu-Natal Province, South Africa, are insufficient for the burden of disease: Is patient care compromised? E Loots,1,2 MB ChB, FCS (SA), Cert Gastroenterology (SA) Surg; D L Clarke,2,3,4 MB ChB, MPhil, MBA, MSc, PhD; K Newton,5 MB ChB, FCP (SA); C J Mulder,6 PhD Department of Surgery, Inkosi Albert Luthuli Central Hospital, Durban, South Africa Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, Durban, South Africa 3 Department of General Surgery, Greyâ&#x20AC;&#x2122;s Hospital, Pietermaritzburg, South Africa 4 Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 5 Department of Gastroenterology, Inkosi Albert Luthuli Central Hospital and School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 6 Department of Hepatogastroenterology, VU University Medical Centre Amsterdam, Netherlands 1 2

Corresponding author: E Loots (emilloots@hotmail.com)

November 2017, Print edition

RESEARCH

Background. Endoscopy services are central to the diagnosis and management of many gastrointestinal (GI) diseases. Objective. To evaluate the adequacy of endoscopy services in the public sector hospitals of KwaZulu-Natal (KZN) Province, South Africa, in 2016. Methods. A cross-sectional study was performed using a questionnaire completed by the clinical heads of endoscopy units in the public hospitals in KZN. Results. The heads of 11 of the 12 endoscopy units responded. Two units were in tertiary-level hospitals and nine in regional hospitals. A total of 22 353 endoscopic procedures were performed annually, averaging 2 032 cases per annum per centre; they were performed by 89Â endoscopists, of whom 72 (80.1%) were general surgeons. There were 0.06 registered gastroenterologists (GEs) per 100 000 population. Each endoscopist performed an average of 263 endoscopies per annum. There were 1.18 endoscopy rooms available per unit, and two units had on-site fluoroscopy available. The average waiting period for an upper endoscopy was 27 (range 7 - 60) days, for colonoscopy 29 (range 7 - 90) days and for duodenoscopy/endoscopic retrograde cholangiopancreatography 13 (range 4 - 20) days. This included patients with alarm symptoms for GI cancers. Equipment breakages interrupted most services, except for one hospital that had a service contract. Unit heads cited lack of equipment, trained staff and maintenance contracts as major shortcomings. Conclusions. Endoscopy units in KZN are not adequately equipped to deal with the endoscopy workload and services are plagued by frequent disruptions, which impact negatively on service delivery. There is a need to train more GEs. Patient care is compromised in these public hospitals. S Afr Med J 2017;107(11):1022-1025. DOI:10.7196/SAMJ.2017.v107i11.12484

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i11.12484

November 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.

GREAT OPPORTUNITY! LOOK NO FURTHER! We are looking for a full-time and part-time GP to join us at our privately owned, rapidly growing general practice at Saratoga, NSW, Australia. We are a DWS practice located in a busy shopping village on the beautiful Brisbane Waters. Our mission is to provide quality healthcare to our patients in a friendly and comfortable setting. We are located approximately 1 hour north of Sydney and 1 hour south of Newcastle – 15 minutes to the M1 motorway. We offer the following: • mixed billing • fully computerised database (Best Practice) • full-time nursing support (RN) • women’s health • allied health services, including chiropractor, dietitian, physiotherapist, podiatrist and psychologist • on-site pathology service • pharmacy in the village, and imaging services in a nearby suburb • flexible hours, with minimal after-hours commitment • great remuneration. We can provide you with all the necessary support and sponsorship to facilitate your move.

For further information, please contact Lisa Porteous at: admin@saratogamedicalcentre.com.au or phone +612 4363 1066

GENERAL PRACTICE Long-established profitable general practice for sale due to doctor retiring. Located in well-serviced popular town close to major cities, and less than 2 hours’ drive from Gauteng cities. Ideal opportunity for great country living! Mediclinic and specialists available.

Contact: Relene, 082 826 1378

CALL LADINE OR MAKHADZI FOR ALL YOUR ADVERTISING NEEDS! You can reach over 15 500 Doctors by advertising with us. LADINE, TEL: +27 (12) 481 2121

LOCUM DOCTOR REQUIRED Part-time/full-time locum doctor required for family practice in Port Elizabeth/Uitenhage area. Starting date, salary and period negotiable.

EMAIL: ladinev@hmpg.co.za

OR MAKHADZI, TEL: +27 (12) 481 2156

Contact: Anneline, 041 995 33 00 (oﬃce hours), or vikesh@iafrica.com

EMAIL: makhadzim@hmpg.co.za

CAREERS & CLASSIFIEDS

Gynaecologist required To join a private practice in Hamilton, New Zealand The Womens Health Centre is seeking a Gynaecologist to join an existing private practice in Hamilton, New Zealand. Hours and remuneration are flexible and negotiable. Experience in Laparoscopic surgery is necessary. You must be eligible for full registration as a Gynaecologist in New Zealand. There is no obstetric component.

Contact naylin@obgyn.co.nz or +6421651193 Women’s Health Centre

Hamilton is New Zealands largest inland city with a population of over 141,000 just about an hour and a half's drive south of Auckland. Hamilton is a naturally beautiful city built on the banks of the Waikato River. Hamilton offers easy, comfortable living, with short commuting times across the city and a relatively relaxed pace and overall vibe. Head west from Hamilton toward the coast and you’ll discover the beachside settlement of Raglan. Internationally renowned with surfers for its left-hand point breaks, Raglan has grown over the years to appeal to a much wider audience than surfer alone. With its laid back atmosphere, stunning surroundings and bustling art scene, Raglan presents a great living option if the lifestyle suits. Not far from Hamilton is the town of Matamata, perhaps these days more famous for being the home of Hobbiton. And of course there are the Waitomo Caves - a world renowned subterranean adventure destination, just an hours’ drive from Hamilton. Head 2 hours south and you could be hitting the ski fields in winter. Just over an hour east is the sunny Bay of Plenty, with the plentiful beaches of Tauranga and Mount Maunganui.

CONSULTANT BREAST RADIOLOGIST • • • • •

Opportunity to grow your career Excellent remuneration package Relocation assistance Innovative practice Positive, supportive, dedicated team

St Marks Group in Auckland, New Zealand seeks a Consultant Breast Radiologist to join our well-established practice and multidisciplinary team of breast specialists. You will have experience in all forms of breast imaging, including digital and analogue mammography, breast ultrasound, as well as ultrasound-guided biopsies, sentinel node injections and Dwire localisations. You should also possess outstanding clinical and interpersonal skills. Full-time or part-time (minimum 0.4 FTE) option considered, with assistance offered to obtain further sessions in general radiology. This is an exciting opportunity to deliver a high-quality customer-centred service in both the private St Marks Breast Centre and the public BreastScreen Auckland clinics. You will be part of a progressive and exciting business and a warm and professional team. This is an excellent place to forge your specialist career and contribute to the very best in patient care. We offer an excellent remuneration package, a sign-on bonus for a radiologist working a minimum of 0.4FTE and relocation assistance.

Please direct applications to: Debbie van Ryswyk Group General Manager St Marks Group d.vanryswyk@smwh.co.nz Phone: (64)-9-5223871 smwh.co.nz

SAOLTA UNIVERSITY HEALTH CARE GROUP, IRELAND Saolta University Health Care Group provides a comprehensive range of medical, surgical, paediatrics, and obstetrics and gynaecology services to emergency and elective patients on an inpatient, outpatient and daycare basis across the West and North West of Ireland. All hospitals in the group play a leadership role in the acute service delivery, serving a catchment area of 1 million people. All hospitals in the Saolta University Health Care Group are aďŹ&#x192;liated to the National University of Ireland at Galway and are involved in the undergraduate and postgraduate training of medical and other healthcare professionals. Saolta University He alth Care Group currently has the follo wing immediate vacancy in their hosp itals â&#x20AC;&#x201C; Galway, Roscommon Universit y Hospital, Letterkenny Universit y Hospital, Mayo University Hospital, Portiuncula Universit y Hospital and Sligo Un iversity Hospital: Locum Consultants Em ergency Medicine

To apply for the abovem entioned post, please send your CV to medicalrecr uitguh@hse.ie Informal enquiries: Mr Brian Mullin, Medical Manpower Manager, Sa olta University Health Care Group, Galway Universi ty Hospitals, on 091-5 42122. Vacancy in Mayo Un iversity Hospital: Locum Consultant Ga stroenterologist/Physi cian To apply for the above mentioned post in Ma yo University Hospital, ple ase send your CV to Annette.kelly@hse.ie

Informal enquiries: An nette Kelly, Medical Ma npower Manager, Saolta Unive rsity Health Care Grou p, Ma yo University Hospital, on 094-9042335.

NICO recruit 210x297 Oct17.qxp_Layout 1 09/10/2017 12:45 Page 1

Work on Tristan da Cunha, the most remote inhabited island in the world... ISLAND DOCTOR(S) or MEDICAL TEAM

required starting early-mid 2018 Requirements: Doctor with broad skills mix and proven experience of Primary Care, General Surgery, Anaesthetics and Obstetrics. or Medical Team with the above skills mix comprising of 2 Doctors or 1 Doctor accompanied by an experienced registered nurse/paramedic. Full registration with the UK General Medical Council (GMC) or similar recognised Medical or relevant Nursing/Paramedical Board required. We accept individual applications from experienced self-sufficient doctors. Consideration would however be given to the deployment of a medical team. We invite suggestions for such a team in your application. Duration: 3-6 month period with option to become part of a small team of suitably qualified doctors to provide the service on a rotational basis for periods of 3-6 months each over a period of 3-5 years. Salary: Attractive package available including free accommodation and travel. Salary negotiable, dependant upon experience and qualifications. Deadline for applications: Friday, 24th November 2017 For full details or to apply: Contact: Lydia Murray Contact email: lmurray@nico.org.uk Website: Application form and Information Pack can be downloaded directly from the following website: http://www.nico.org.uk Address: NI-CO, Landmark House, 5 Cromac Quay, BELFAST BT7 2JD

For more information about life on Tristan da Cunha visit: www.tristandc.com

CPD

NOVEMBER 2017

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 Kaposi’s sarcoma: Good outcome with doxorubicin, bleomycin and vincristine sulphate (ABV) chemotherapy and highly active antiretroviral therapy 1. Although the incidence of Kaposi’s sarcoma in some African countries is decreasing because of highly active antiretroviral therapy, it remains an important cause of childhood cancer. Sensory integration intervention and the development of the premature infant 2. Small-for-gestational-age and extremely-low-birth-weight premature infants are at risk of developing sensory integration difficulties. 3. Research indicates that during the first 1 000 days of life (from conception to age 3), children’s brains can form 1 000 neural connections per second. 4. Self-regulation activities [in infants] include finger or dummy sucking, finger playing, self-rocking and looking at or listening to preferred visual or auditory stimuli. Access to and utilisation of healthcare services by sex workers at truck-stop clinics in South Africa (SA) 5. Sex workers face a higher HIV burden and have less access to healthcare than the general population. 6. Currently, most sex worker projects focus on prevention of HIV and sexually transmitted infections. Near-miss maternal morbidity from severe haemorrhage at caesarean section: A process and structure audit of system deficiencies in SA 7. Recent increases in maternal death in SA are believed to be the combination of a rising caesarean section rate combined with substandard surgery and postoperative care, leading to an increase in bleeding during and after caesarean section. 8. Reasons for a rising caesarean section rate in SA are poor obser vation of women in labour, poor interpretation of cardiotoco graphic tracings, healthcare worker delays in attending to obstetric emergencies, and a preference by healthcare workers for caesarean section over assisted deliveries.

Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XL-MAC system 9. Estimated weights [in children] have been shown to be extremely inaccurate in many settings, with some studies in underweight and obese populations having shown weight estimations to be inaccurate in up to 85% of children. 10. Depending on the drugs to be used, there are situations where estimations of both total body weight and ideal body weight may be required to optimise drug administration. CME Lessons learnt from the introduction of the contraceptive implant in SA 11. The term ‘boom-and-bust’ in family planning describes the phenomenon in which there is an initial boom in use of a new contraceptive technology, coupled with excitement and optimism, followed by a rapid downturn due to unmet expectations and disappointment. 12. Bias when introducing a new contraceptive method may hamper the provision of complete information and counselling. 13. Focus on the technological advantages of implants may over shadow the impact and tolerability of side-effects. 14. Removal of the contraceptive implant is uncommon in most settings. Reasons for early removal include inadequate counselling, 15. dissatisfaction with the method, lack of support while using the method and poor management of side-effects. Strengthening implant provision and acceptance in SA with the ‘Any woman, any place, any time’ approach: An essential step towards reducing unintended pregnancies 16. Progress in reducing unintended pregnancies in SA is slow. 17. I mplants can be offered immediately postpartum and post-abortion. 18. Limited access to removal services, health workers’ resistance or botched procedures will further undermine implant provision. 19. Professional bodies in the USA recommend that contraceptive implants are the best reversible method for preventing unintended pregnancy, rapid repeat pregnancy and abortion in young women. 20. Between 2014/2015 and 2016/2017, the numbers of implants inserted in the SA public sector have risen.

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

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

INSTRUCTIONS 1. Read the journal. All the answers will be found there, in print or online. 2. Go to www.mpconsulting.co.za to answer the questions. Accreditation number: MDB015/047/01/2017

November 2017, Print edition

ARE YOU OPENING A NEW MEDICAL PRACTICE?

We can assist with all your opening order needs! GAUTENG BRANCH:

Tel: 012 377 9000 Email: clientservice@transpharm.co.za Email: orders@transpharm.co.za

WESTERN CAPE BRANCH: Tel: 021 929 2120 Email: infowc@transpharm.co.za

www.transpharm.co.za

Bring back the

with…

Packed in 30’s

Effective in relieving GORD symptoms1 Achieves better and quicker healing rates of erosive esophagitis, when compared to other PPIs1 Improves health-related quality of life1 Is well tolerated2 Reimbursed by ALL medical aids 3

References: 1. Kalaitzakis E, Björnsson E. A review of esomeprazole in the treatment of gastroesophageal reflux disease (GERD). Therapeut & Clin Risk Management 2007;3(4):653-663. 2. Scheiman JM, Yeomans ND, Talley NJ, et al. Prevention of Ulcers by Esomeprazole in At-Risk Patients Using Non-Selective NSAIDs and COX-2 Inhibitors. Am J Gastroenterol 2006;101:701-710. 3. Data on File: Ranbaxy (SA) (Pty) Ltd. S4 Nexipraz® 20 Gastro-resistant tablets. Reg. No. 45/11.4.3/0125. Each gastro-resistant tablet contains esomeprazole magnesium 20,7 mg equivalent to esomeprazole 20 mg. Contains sugar. S4 Nexipraz® 40 Gastro-resistant tablets.Reg. No. 45/11.4.3/0126. Each gastro-resistant tablet contains esomeprazole magnesium 41,4 mg equivalent to esomeprazole 40 mg. Contains sugar. For full prescribing information please refer to the package insert approved by the medicines regulatory authority. Applicant: Ranbaxy (SA) (Pty) Ltd, a SUN PHARMA company, Ground Floor, Tugela House, Riverside Office Park, 1303 Heuwel Avenue, Centurion, 0046. Tel: +27 12 643 2000. Fax: +27 12 643 2001. www.sunpharma.com.