Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420210009&lang=en vol. 111 num. 9 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Vaccine hesitancy? No, government failure</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900001&lng=en&nrm=iso&tlng=en <![CDATA[<b>The National Health Insurance Bill: Responses and options for the Portfolio Committee on Health</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Re-evaluating blood culture incubation times during SARS-CoV-2: Can we shorten incubation times without compromising results?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Zimbabwe's COVID-19 vaccination roll-out: Urgent need to rethink strategies to improve the supply chain</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Commencement of medical internship during the COVID-19 pandemic: An honour with increased responsibility</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900005&lng=en&nrm=iso&tlng=en <![CDATA[<b>A call to action: Temporal trends of COVID-19 deaths in the South African Muslim community</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900006&lng=en&nrm=iso&tlng=en <![CDATA[<b><i>Listeria monocytoge-knees </i>infection: An unusual presentation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900007&lng=en&nrm=iso&tlng=en <![CDATA[<b>Dr Mahomed H Amla, 1 September 1949 - 31 December 2020</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Dr Piet Gonin</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900009&lng=en&nrm=iso&tlng=en <![CDATA[<b>Stillbirth rate by maternal HIV serostatus and antiretroviral use in pregnancy in South Africa: An audit</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900010&lng=en&nrm=iso&tlng=en <![CDATA[<b>Thalassaemia (part 2)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900011&lng=en&nrm=iso&tlng=en <![CDATA[<b>Thalassaemia (part 2): Management</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900012&lng=en&nrm=iso&tlng=en The management of thalassaemia with a severe phenotype includes blood transfusion, iron chelation, bone marrow transplantation, prenatal diagnosis and national programmes to co-ordinate these in countries with a high prevalence. If blood transfusion and iron chelation therapy are not administered regularly, as was the case historically and as is still the case in many poorer regions, progressive deterioration occurs, viz. impaired growth and development, hepatosplenomegaly, bony abnormalities, cardiac failure, increased susceptibility to infections and premature mortality. Remarkable progress has been made in the past few decades, which has led to much-improved survival rates. Transfusion therapy has evolved to a hyper-transfusion regimen designed to maintain a physiological haemoglobin level and achieve a posttransfusion haemoglobin of 14 g/dL, which, as a matter of course, necessitated intensification of iron chelation. The development of effective oral iron chelators has led to improved compliance. Exploration of novel therapeutic approaches continues, with several agents under study. The prospect of gene therapy is particularly exciting as it has potential to provide cure on a large scale. Currently, regular blood transfusion and iron chelation therapy remain the cornerstone of management of thalassaemia major. <![CDATA[<b>Unnatural deaths, alcohol bans and curfews: Evidence from a quasi-natural experiment during COVID-19</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900013&lng=en&nrm=iso&tlng=en BACKGROUND. Coronavirus disease-19 (COVID-19) restrictions, particularly relating to the sale of alcohol and hours of curfew, have had a marked effect on the temporal pattern of unnatural deaths in South Africa. METHODS. Death data were collected over 68 weeks from January 2020 to April 2021, together with information on the nature of restrictions (if any) on the sale of alcohol, and hours of curfew. Data were analysed using a simple ordinary least square (OLS) regression model to estimate the relative contribution of restrictions on the sale of alcohol and hours of curfew to the pattern of excess unnatural deaths. RESULTS. The complete restriction on the sale of alcohol resulted in a statistically significant reduction in unnatural deaths regardless of the length of curfew. To the contrary, periods where no or limited restrictions on alcohol were in force had no significant effect, or resulted in significantly increased unnatural deaths. CONCLUSION. The present study highlights an association between alcohol availability and the number of unnatural deaths and demonstrates the extent to which those deaths might be averted by disrupting the alcohol supply. While this is not a long-term solution to addressing alcohol-related harm, it further raises the importance of implementing evidence-based alcohol control measures. <![CDATA[<b>Engaging surgeons among clinician-scientists</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900014&lng=en&nrm=iso&tlng=en Since completion of the Human Genome Project at the turn of the century, there have been significant advances in genomic technologies together with genomics research. At the same time, the gap between biomedical discovery and clinical application has narrowed through translational medicine, so establishing the era of personalised medicine. In bridging these two disciplines, the clinician-scientist has become an integral part of modern practice. Surgeons and surgical diseases have been less represented than physicians and medical conditions among clinician-scientists and research. Here, we explore the possible reasons for this and propose strategies for moving forward. Discovery-driven personalised medicine is both the present and the future of clinical patient care worldwide, and South Africa is uniquely placed to build capacity for biomedical discovery in Africa. Diverse engagement across clinical disciplines, including surgery, is necessary in order to integrate modern medicine into a developing-world contextualised perspective. <![CDATA[<b>Heparin-induced thrombocytopenia: An update for the COVID-19 era</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900015&lng=en&nrm=iso&tlng=en The increased use of heparin during the current COVID-19 pandemic has highlighted the risk of a rare but potentially serious complication of heparin therapy, viz. heparin-induced thrombocytopenia (HIT). This is a short review on the pharmacology of heparin and its derivatives, and the pathophysiology of HIT. Guidance on laboratory testing for and clinical management of HIT is presented in accordance with international guidelines. There are important similarities and differences between HIT and the new entity of vaccine-induced immune thrombotic thrombocytopenia, also known as thrombosis with thrombocytopenia syndrome, which clinicians need to be aware of. <![CDATA[<b>Patterns of oxygen saturation in prolonged recovery from COVID-19 pneumonia</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900016&lng=en&nrm=iso&tlng=en During the second wave of the COVID-19 pandemic in South Africa, a recurrent pattern of prolonged recovery after acute COVID-19 pneumonia, characterised by low oxygen saturation levels for >2 weeks, was observed in an intermediate-care facility in Cape Town. A case study together with a series of 12 patients is presented to illustrate this phenomenon, and two types of 'sats gap' are described, which were used by physiotherapists and doctors to monitor daily progress. We attempt to explain this prolonged recovery in terms of the possible pathophysiology, and suggest a number of learning points to guide further research. <![CDATA[<b>COVID-19 herd immunity v. learning to live with the virus</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900017&lng=en&nrm=iso&tlng=en Mutations of SARS-CoV-2 have been associated with increased transmissibility and occasionally reduced sensitivity to neutralising antibody activity induced by past ancestry virus infection or current COVID-19 vaccines. Nevertheless, COVID-19 vaccines have consistently demonstrated high efficacy and effectiveness against COVID-19 severe disease, hospitalisation and death, including disease caused by designated variants of concern. In contrast, COVID-19 vaccines are more heterogeneous in reducing the risk of infection and mild COVID-19, and are modestly effective in interrupting virus transmission. Ongoing mutations of SARS-CoV-2 resulting in increased transmissibility and relative evasion of neutralising antibody activity induced by past virus infection or COVID-19 vaccines are likely. The duration of protection induced by COVID-19 vaccines is modelled to be relatively short in protecting against infection and mild COVID-19, but is likely to be 2 - 3 years against severe disease. Current experience from the UK and Israel demonstrates that even with high levels of COVID-19 vaccine coverage (>85% of the adult population), resurgences with new variants of concern remain a strong probability. Nevertheless, such resurgences are not mirrored by high rates of hospitalisation and death compared with what was experienced in relatively COVID-19 vaccine-naive populations. Even though COVID-19 vaccines are unlikely to result in a herd immunity state, their ability to protect against severe COVID-19 and death could allow for a return to normalcy once a large enough proportion of the adult population in a country has been vaccinated. <![CDATA[<b>Evaluating the performance of the GeneXpert HIV-1 qualitative assay as a consecutive test for a new early infant diagnosis algorithm in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900018&lng=en&nrm=iso&tlng=en BACKGROUND. The proportion of HIV-exposed infants and young children infected with HIV in South Africa (SA) has declined markedly over the past decade as a result of the country's comprehensive prevention of mother-to-child transmission programme. This decrease has in turn reduced the positive predictive value (PPV) of diagnostic assays, necessitating review of early infant diagnosis (EID) algorithms to ensure improved accuracy. OBJECTIVES. To evaluate the performance of the GeneXpert HIV-1 qualitative assay (Xpert EID) as a consecutive test for infants with an 'HIV-detected' polymerase chain reaction screening test at birth. METHODS. We retrospectively analysed a longitudinal cohort of HIV-exposed infants on whom birth testing was performed, using whole-blood ethylenediaminetetra-acetic acid samples, from four tertiary sites in Gauteng Province between June 2014 and December 2019. Birth samples from all infants with a Cobas AmpliPrep/Cobas TaqMan HIV-1 Qualitative Test v2.0 (CAP/CTM v2.0) HIV-detected screening test, a concurrent Xpert EID test and a subsequent confirmatory CAP/CTM v2.0 test on a separate specimen were included. Performance of the Xpert EID in predicting final HIV status was determined as proportions with 95% confidence intervals (CIs). A comparison of indeterminate CAP/CTM v2.0 results, as per National Health Laboratory Service resulting practice, with discordant CAP/CTM v2.0 v. Xpert EID results was performed. RESULTS. Of 150 infants who met the inclusion criteria, 6 (3.9%) had an Xpert EID result discordant with final HIV status: 5 (3.3%) were false negatives and 1 (0.7%) was false positive. As a consecutive test, the Xpert EID yielded a sensitivity of 96.5% (95% CI 92 - 98.9), specificity of 85.7% (95% CI 42.1 - 99.6), PPV of 99.3% (95% CI 95.7 - 99.9), negative predictive value of 54.5% (95% CI 32.5 - 74.9) and overall accuracy of 96.1% (95% CI 91.5 - 98.5). Using discordant CAP/CTM v2.0/Xpert EID results as criteria to verify indeterminate results instead of current practice would have reduced the number of indeterminate screening results by 42.1%, from 18 (12.6%) to 11 (7.2%), without increasing the false-positive rate. CONCLUSIONS. Addition of the Xpert EID as a consecutive test for specimens with an HIV-detected PCR screening result has the potential to improve the PPV and reduce the indeterminate rate, thereby reducing diagnostic challenges and time to final status, in SA's EID programme. <![CDATA[<b>Clinical aspects and outcomes of patients with malaria at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900019&lng=en&nrm=iso&tlng=en BACKGROUND. South Africa (SA) is currently experiencing a significant increase in malaria cases despite having shifted focus from malaria control towards malaria elimination. The clinical features of malaria are nonspecific, but their relative frequency on presentation are not well described. HIV and malaria are both independently associated with high mortality in sub-Saharan Africa. There are important interactions between HIV and malaria. OBJECTIVES. To describe the population characteristics of patients with malaria at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, clinical and biochemical features of severity, the proportion of patients with HIV infection, management and outcomes. METHODS. A prospective observational study was conducted whereby patients with a confirmed laboratory diagnosis of malaria were identified, approached and consented for study inclusion over the time period January 2017 - January 2018. Clinical and biochemical data were collected at the time of consent and later analysed. RESULTS. The mean (standard deviation) age was 35.7 (12.98) years, and 72 (70.6%) of the 102 patients were male. Peak admissions for malaria were in January, with 58 patients (56.9%) admitted during January 2017 and 2018. All malaria cases were imported, with 74.5% associated with travel to Mozambique. The majority of the patients (61.8%) were expatriates living in SA. The most common presenting symptoms were chills (95.1%), weakness (94.1%), fever (91.2%), headache (90.2%) and lethargy (88.2%). The most common clinical signs were dehydration (31.4%), prostration (19.6%) and jaundice (13.7%). Among the 40 patients (39.2%) who had severe malaria, prostration was the most common feature of severity (19.6%), 8 (7.8%) were admitted to an intensive care unit, and 6 (5.9%) required haemodialysis. The median (interquartile range) duration of hospital stay was 5 (3 -6) (range 2 - 35) days. HIV status was known in 83 patients (81.4%), of whom 32 (38.6%) were HIV-positive. Malaria prophylaxis had been taken by only 8 patients. The all-cause mortality rate was 4.9%, and mortality attributable to malaria 3.9%. CONCLUSIONS. There was a high proportion of complicated malaria cases, particularly in January. The majority of patients were young expatriate males with a history of travel to southern Mozambique or Limpopo Province, with very few taking malaria prophylaxis. Most clinical signs and symptoms were constitutional and nonspecific. A large number of patients were found to be HIV-positive, and most were newly diagnosed. Mortality was high, at around five times the national average, and may have been an underestimate. <![CDATA[<b>Determining the prevalence of tuberculosis in emergency departments in the Eastern Cape region of South Africa and the utility of the World Health Organization tuberculosis screening tool</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900020&lng=en&nrm=iso&tlng=en BACKGROUND. South Africa (SA) faces a significant tuberculosis (TB) burden complicated by high rates of HIV-TB co-infection. In SA, emergency departments (EDs) play an important role in screening for TB. OBJECTIVES. To determine the prevalence of TB in the ED and the effectiveness of the World Health Organization (WHO) TB screening tool. Methods. This was a cross-sectional observational study, conducted in the ED at Livingstone Hospital, Port Elizabeth, from 4 June to 15 July 2018. All patients aged &gt;18 years and able to consent were administered the WHO TB screening questions and underwent a point-of-care HIV test and demographic data collection. Patients were followed up for 1 year and tracked in the National Health Laboratory Service database to determine TB status using laboratory testing. RESULTS. Over the study period, 790 patients were enrolled. Overall, 121 patients (15.3%) were TB-positive, with 46 (38.0%) diagnosed after presenting to the ED and 75 (62.0%) with a previous TB history determined by self-report or confirmed laboratory testing. A greater proportion of the TB-positive patients were HIV-positive (49.6%) compared with the TB-negative population (24.8%). TB-positive individuals were more likely to present to the ED with a chief complaint of shortness of breath (SoB) (18.2%) compared with the TB-negative population (10.5%). Overall, the WHO TB screening tool had poor sensitivity (46.5%) and specificity (62.5%) for identifying TB-positive patients in the ED. A multiple logistic regression analysis, controlled for age and sex, showed HIV status (odds ratio (OR) 2.81; p<0.001) and SoB (OR 2.19; p<0.05) to be significant predictors of TB positivity. Adding positive HIV status and a presenting complaint of SoB increased sensitivity to 78.3%. CONCLUSIONS. EDs in SA face a high burden of TB. While WHO screening guidelines identify some of these patients, including routine HIV testing in the ED could significantly affect the number of TB diagnoses made. <![CDATA[<b>Patterns of leprosy at Chiis Hani Baragwanath Academic Hospital, Johannesburg, South Africa, and review of current clinical practice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900021&lng=en&nrm=iso&tlng=en BACKGROUND. The World Health Organization announced a strategy to eliminate childhood leprosy infections, visible deformities and discriminatory legislation against leprosy patients by 2020. However, challenges in achieving a leprosy-free world and preventing neurological sequelae still exist. HIV infection is a challenge in South Africa (SA). HIV-leprosy co-infection may result in an increase in the frequency of leprosy reactions without affecting the spectrum of leprosy. From 1921 to 1997, the prevalence of leprosy remained <1 patient per 10 000 population. Current SA literature has very scanty information regarding leprosy infections. OBJECTIVES. To describe the trend of new leprosy patients at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, from 1999 to 2015, including demographics, clinical spectrum and treatment outcomes. METHODS. A retrospective review of patients' clinical records was undertaken. Data on demographics, clinical spectrum including the leprosy classification, reactions, neurological involvement, association with HIV infection and treatment outcomes were extracted. Data analysis was performed using descriptive and inferential statistics and a time series analysis. RESULTS. An upward trend from 1999 to 2001 was followed by a decline in the number of new patients. Eighty patients were registered over a period of 17 years, with a male-to-female ratio of 3:1. Thirty-six patients were immigrants, and 5 were children aged <15 years. Multibacillary leprosy was the most common type (n=71 patients). Thirty-six patients had the lepromatous leprosy subtype, 22 were borderline lepromatous, 13 were borderline tuberculoid, 6 were borderline borderline, and 3 had tuberculoid leprosy. Thirty-one patients presented with reactions, type 1 in 9 patients and type 2 in 21 patients, with both types in 1 patient. Grade 2 neurological deformities were diagnosed in 37 patients, of whom 2 were children. Eight patients were found to have HIV-leprosy co-infection. Of 52 patients who completed treatment, 26 were cured and 26 were lost to follow-up. Twenty-one patients defaulted from treatment, while 3 patients relapsed. CONCLUSIONS. This study highlights the current status of leprosy in a low-endemic centre with declining numbers of new patients. Multibacillary forms with grade 2 disabilities (G2Ds) are common. The constant emergence of leprosy in our population highlights shortfalls in our control campaigns. Furthermore, a high rate of G2Ds necessitates scrutiny of education directed at early patient detection and follow-up strategies. <![CDATA[<b>Significance of HbAlc levels in diabetic retinopathy extremes in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900022&lng=en&nrm=iso&tlng=en BACKGROUND. Diabetic retinopathy (DR) is one of the leading causes of blindness in sub-Saharan Africa and globally, placing a huge disease burden on patients and the public health system. DR varies in severity from non-proliferative to proliferative DR (PDR). OBJECTIVES. Using a monitor of medium- to long-term blood glucose control, to determine the association between glycated haemoglobin (HbA1c) levels in patients with PDR and those with no DR. METHODS. A prospective, cross-sectional study was conducted at McCord Provincial Eye Hospital in Durban, South Africa. We studied only patients diagnosed with diabetes mellitus (DM) for >1 year who had either PDR or no DR, and compared their HbA1c levels. Patients with non-proliferative DR were not included. RESULTS. Patients with PDR had significantly higher HbA1c levels than those with no DR. Patients with type 1 DM had higher HbA1c levels than patients with type 2 DM in both the PDR and no-DR groups. Older patients (>70 years) had lower HbA1c levels than younger patients. Gender, race and duration of diabetes had no influence on HbA1c levels. CONCLUSIONS. PDR was associated with higher HbA1c in type 2 DM in all races and age groups and was independent of duration of disease. The trend was the same for type 1 DM, but significance could not be reached, probably because of small numbers in this subset of patients. <![CDATA[<b>The reliability of physical examination in diagnosing arterial injury in penetrating trauma to extremities: A first look at different anatomical regions and injury mechanisms</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900023&lng=en&nrm=iso&tlng=en BACKGROUND. The accuracy of physical examination to exclude arterial injury in penetrating trauma to extremities has been well established. Objectives. To determine whether the accuracy of physical examination to exclude arterial injury is similar to that of a computed tomography arteriogram (CTA) for different anatomical regions and mechanisms of injury, and in patients with concomitant fractures compared with those without. METHODS. A retrospective review was conducted on all patients who underwent CTA for penetrating injuries to an extremity between 1 June 2016 and 30 June 2017. The presence of arterial injuries was noted, and these were grouped into anatomical areas. Clinical notes were reviewed for the presence of hard signs of arterial injury at initial examination. RESULTS. A total of 220 lower limb and 133 upper limb CTAs were included. The mean patient age was 28.9 years (range 11 - 68). The overall sensitivity of physical examination in detecting a CTA-confirmed arterial injury was 95.3% (95% confidence interval (CI) 88.4 - 98.7), with a specificity of 93.9% (95% CI 90.2 - 96.4). Physical examination of the thigh had the highest specificity of 96.4% (95% CI 91.8 - 98.8), followed by the lower leg at 94.4% (95% CI 81.3 - 99.3), the upper arm at 89.6% (95% CI 79.7 - 95.7) and the forearm at 77.8% (95% CI 40.0 - 97.2). For gunshot wounds the specificity was 96.1% (95% CI 92.4 - 98.3), while for stab wounds it was 86.8% (95% CI 74.7 - 94.5). CONCLUSIONS. This study agrees with current literature indicating that physical examination has high specificity in detecting arterial injury in the setting of penetrating trauma to an extremity. However, it shows that the specificity is not equal for all anatomical regions or mechanisms of injury. <![CDATA[<b>The incidence of fragility hip fractures in a subpopulation of South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900024&lng=en&nrm=iso&tlng=en BACKGROUND. Fragility hip fractures (FHFs) are associated with significant morbidity, mortality and burden on the healthcare system. European and North American literature suggests that the worldwide incidence of FHFs is increasing, but very little is known about the incidence of FHFs in Africa and South Africa (SA). Historically FHFs were believed to be uncommon in black African populations, but recent studies have shown a marked increase in the incidence compared with the early literature. OBJECTIVES. To investigate the age-, gender- and population group-specific incidences of FHFs in a subpopulation in Eastern Cape Province, SA. Methods. A retrospective review of all patients presenting with FHFs was performed at a tertiary hospital in the Eastern Cape over a 1-year period. Age-, gender- and population group-specific incidence rates were calculated for 5-year age intervals using the age distribution data of the western region of the Eastern Cape (WREC) as a denominator for each age group. Overall crude incidence rates were calculated by using the sum total of FHFs, divided by the study population. All incidences were calculated as number of fractures per 100 000 people annually. Results. A total of 253 patients with FHFs were included. The crude incidence rate of low-energy hip fractures in the WREC was 19.3 per 100 000 (males 14.6, females 23.4) over the study period. Population group-specific incidences were 15.1, 18.7, 19.9 and 46.6 per 100 000 for black, coloured, Indian and white population groups, respectively. The highest number of low-energy hip fractures in females occurred in the &gt;85-year (19.6%) and 70 - 74-year (16.5%) age groups, with the highest number of male cases observed in the 60 - 64-year group (20.2%). The highest frequency distribution of FHFs was observed in black males aged 60 - 64 years (5.5%; n=14) and black females aged 70 - 74 years (6.3%; n=16). CONCLUSIONS. The local incidence of FHFs is higher than initially reported, but when compared with other countries remains on the lower end of spectrum. A large proportion of FHFs are occurring in young patients (<65 years). These findings warrant further investigation that may prompt the development of preventive strategies and optimal treatment programmes. <![CDATA[<b>Investigating the need for therapeutic drug monitoring of imipenem in critically ill patients: Are we getting it right?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900025&lng=en&nrm=iso&tlng=en BACKGROUND. The drug levels and clearances of imipenem in critically ill patients are not comprehensively described in current literature, yet it is vital that adequate levels be achieved for therapeutic success. OBJECTIVES. To determine the proportion of critically ill patients treated with imipenem/cilastatin with sub-therapeutic imipenem plasma levels, and to compare the clinical outcomes of those patients with therapeutic levels with those who had sub-therapeutic levels. Methods. Trough imipenem plasma levels of 68 critically ill patients from a surgical intensive care unit were measured using a validated high-performance liquid chromatography method. Imipenem trough levels were compared with the minimum inhibitory concentration (MIC) of the causative bacterial agents, based on a target value of 100% time above MIC (/T >MIC). RESULTS. The proportion of participants with sub-therapeutic imipenem levels was 22% (95% confidence interval (CI) 13% - 34%). The 14- and 28-day mortality rates in the sub-therapeutic group were 33% and 40%, respectively, compared with 19% (p=0.293) and 26% (p=0.346), respectively, in the therapeutic group. Sub-therapeutic imipenem plasma levels are associated with adjusted hazard ratio of 1.47 (95% CI 0.55 - 3.91). CONCLUSIONS. The lower proportion of critically ill patients with sub-therapeutic imipenem plasma levels in this study compared with previous studies may be attributed to the practice of higher dosages and the administration method of extended infusions of imipenem/ cilastatin in our setting. The results demonstrate a trend of higher mortality in patients with sub-therapeutic imipenem levels, although the results were not statistically significant at this sample size. <![CDATA[<b>Magnetic resonance imaging diagnosis of causes of cerebral palsy in a developing country: A database of South African children</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900026&lng=en&nrm=iso&tlng=en BACKGROUND. Cerebral palsy (CP) is a common worldwide disabling disorder. However, data about prevalence and causes of CP in developing countries are deficient because of high cost and limited availability of magnetic resonance imaging (MRI), the gold standard neuro-imaging modality for evaluation and management of CP in neonates. OBJECTIVES. To determine the frequency of CP causes in children with suspected hypoxic ischaemic injury (HII) involved in medicolegal litigation in South Africa based on MRI report findings. METHODS. A total of 1 620 MRI reports were categorised into HII, non-HII and normal MRI. None of the patients had prior neuro-imaging records. HII reports were sub-classified according to pattern of brain injury into basal ganglia-thalamus (BGT), watershed (WS), combined BGT-WS, periventricular leukomalacia (PVL) and multicystic encephalomalacia. Non-HII diagnoses were sub-classified into strokes, congenital malformations, kernicterus, hydrocephalus, haemorrhages, atrophies, metabolic causes and infections. RESULTS. The median age was 6 years. HII reports (n=1 233; 76.1%) showed BGT in 447 (27.6%), WS in 266 (16.4%), combined BGT-WS in 335 (20.7%), PVL in 58 (3.6%) and multicystic in 127 (7.8%). Non-HII diagnoses (n=255; 15.7%) showed 78 (4.8%) congenital malformations, 50 (3.1%) atrophies, 35 (2.1%) kernicterus, 23 (1.4%) strokes, 12 (0.8%) haemorrhages, 14 (0.9%) hydrocephalus, 36 (2.1%) metabolic and 7 (0.5%) infections. Normal exams were 132 (8.2%). CONCLUSIONS. Despite being performed a relatively long time - median of 6 years - after the suspected perinatal HII, MRI yielded a diagnosis in 92% and showed that only 76% were due to HII, and more importantly, that there was a preterm HII pattern of injury in 15%, which when added to the 16% of non-HII cases, could potentially save on litigation in a total of 31% of cases that are unlikely to be related to malpractice. MRI should be performed wherever possible in CP cases, even if no imaging exam was performed in the perinatal period. <![CDATA[<b>Erratum</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742021000900027&lng=en&nrm=iso&tlng=en BACKGROUND. Cerebral palsy (CP) is a common worldwide disabling disorder. However, data about prevalence and causes of CP in developing countries are deficient because of high cost and limited availability of magnetic resonance imaging (MRI), the gold standard neuro-imaging modality for evaluation and management of CP in neonates. OBJECTIVES. To determine the frequency of CP causes in children with suspected hypoxic ischaemic injury (HII) involved in medicolegal litigation in South Africa based on MRI report findings. METHODS. A total of 1 620 MRI reports were categorised into HII, non-HII and normal MRI. None of the patients had prior neuro-imaging records. HII reports were sub-classified according to pattern of brain injury into basal ganglia-thalamus (BGT), watershed (WS), combined BGT-WS, periventricular leukomalacia (PVL) and multicystic encephalomalacia. Non-HII diagnoses were sub-classified into strokes, congenital malformations, kernicterus, hydrocephalus, haemorrhages, atrophies, metabolic causes and infections. RESULTS. The median age was 6 years. HII reports (n=1 233; 76.1%) showed BGT in 447 (27.6%), WS in 266 (16.4%), combined BGT-WS in 335 (20.7%), PVL in 58 (3.6%) and multicystic in 127 (7.8%). Non-HII diagnoses (n=255; 15.7%) showed 78 (4.8%) congenital malformations, 50 (3.1%) atrophies, 35 (2.1%) kernicterus, 23 (1.4%) strokes, 12 (0.8%) haemorrhages, 14 (0.9%) hydrocephalus, 36 (2.1%) metabolic and 7 (0.5%) infections. Normal exams were 132 (8.2%). CONCLUSIONS. Despite being performed a relatively long time - median of 6 years - after the suspected perinatal HII, MRI yielded a diagnosis in 92% and showed that only 76% were due to HII, and more importantly, that there was a preterm HII pattern of injury in 15%, which when added to the 16% of non-HII cases, could potentially save on litigation in a total of 31% of cases that are unlikely to be related to malpractice. MRI should be performed wherever possible in CP cases, even if no imaging exam was performed in the perinatal period.